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PREVENTIVE AND COMMUNITY MEDICINE IN PRIMARY CARE

A Conference Sponsored by The John E. Fogarty International Center for Advanced Study in the Health Sciences and the Association of the Teachers of Preventive Medicine

National Institutes of Health Bethesda, Maryland

William H. Barker, M.D. Editor

DHEW Publication No. (NIH) 76-879 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Institutes of Health { Hr4'&.£ u\

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For Sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402— Price $4.90 (cloth) Stock Number 017-053-00051-5 This monograph is the fifth in a series on the TEACHING OF PREVENTIVE MEDICINE

sponsored by the

John E. Fogarty International Center for Advanced Study in the Health Sciences

and the

Association of Teachers of Preventive Medicine

PARTICIPANTS AND CONTRIBUTORS

Dr. Herbert K. Abrams, Department of Family and Community Medicine, College of Medicine, The University of Arizona, Tucson, Arizona Dr. Len H. Andrus, Department of Family Practice, University of California, Davis, School of Medicine, Davis, California Dr. Richard M. Baker, Department of Family Medicine, University of Washington, School of Medicine, Seattle, Washington Dr. William H. Barker, Department of Preventive Medicine and Community Health, School of Medicine and Dentistry, University of Rochester, Rochester, New York Dr. Robert L. Berg, Department of Preventive Medicine and Community Health, School of Medicine and Dentistry, University of Rochester, Rochester, New York John Braun, Bureau of Health Resources Development, Atlanta, Georgia Dr. Valerie Buyse, Department of Family and Community Medicine, University of Arizona, College of Medicine, Tucson, Arizona Dr. C. Hilmon Castle, Department of Community and Family Medicine, University of Utah, College of Medicine, Salt Lake City, Utah Dr. Cora Christian, Howard University, College of Medicine, Washington, D.C. Dr. Leslie A. Falk, Department of Family and Community Health, Meharry Medical College, School of Medicine, Nashville, Tennessee Dr. Eugene Farley, Department of Community Medicine, University of Rochester, School of Medicine and Dentistry, Rochester, New York Dr. Count Gibson, Department of Community and Preventive Medicine, Stanford University, School of Medicine, Stanford, California Dr. Gordon Hall, Rockford School of Medicine, University of Illinois, Rockford, Illinois Dr. Rugh Henderson, Department of Family and Community Medicine, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania Ms. Susan M. Horowitz, National Physicians Assistants Program, Bureau of Health Resources, Bethesda, Maryland

Dr. James I. Hudson, Director, Department of Health Services, Association of American Medical Colleges, Washington, D.C. Dr. William L. Kissick, Department of Community Medicine, University of Penn- sylvania, School of Medicine, Philadelphia, Pennsylvania Dr. William E. Matory, College of Medicine, Howard University, Washing- ton, D.C.

Dr. Fred R. McCrumb, Jr., Special Assistant to the Director, Fogarty International Center, National Institutes of Health, Bethesda, Maryland Dr. Ian McWhinney, The University of Western Ontario, Faculty of Medicine, London, Ontario, Canada Dr. Louis Miller, Department of Social and Preventive Medicine, University Hospital, Baltimore, Maryland

v vi / Prevention in Primary Care

Dr. Charles Payton, University of Rochester, School of Medicine and Dentistry, Family Medicine Program, Rochester, New York Dr. F. Douglas Scutchfield, Office of the Field Professor, Department of Com- munity Medicine, University of Kentucky, Morehead, Kentucky Dr. Stephen Smith, University of Rochester, School of Medicine and Dentistry, Family Medicine Program, Rochester, New York Dr. Vernon Smith, Howard University, College of Medicine, Washington, D.C.

Dr. Joseph Stokes III, Department of Community Medicine, University of Cali- fornia, San Diego, School of Medicine, La Jolla, California Dr. Jesse W. Tapp, Department of Family and Community Medicine, University of Arizona, College of Medicine, Tucson, Arizona Dr. George Thomson, Department of Preventive Medicine, The Medical College of Wisconsin, Milwaukee, Wisconsin Dr. Venita Thweatt, 6319 Landover Road, Cheverly, Maryland Dr. Donald F. Treat, Department of Community Medicine, University of Roches-

ter, School of Medicine and Dentistry, Rochester, New York Dr. James E. C. Walker, Department of Community Medicine and Health Care, University of Connecticut, School of Medicine^ Farmington, Connecticut PREFACE

The Fogarty International Center was established in 1968 as a memorial to the late Congressman John E. Fogarty from Rhode Island. It had been Mr. Fogarty’s desire to create within the National Institutes of Health a center for research in biology and medicine dedicated to international cooperation and collaboration in the interest of the health of mankind.

The Fogarty International Center is a unique resource within the Federal establishment, providing a base for expansion of America’s health research and health care to lands abroad and for bringing the talents and resources of other nations to bear upon the many and varied health problems of the United States. As an institution for advanced study, the Fogarty International Center has embraced the major themes of medical education, environmental health, societal factors influencing health and disease, geographic health problems, international health research and education, and preventive medicine. Our commitment to the study of preventive aspects of human disease is expressed in the forthcoming Fogarty International Center Series on Preventive Medicine. Improvement in the health status of the American people will depend, in great measure, on the design and application of programs which place major emphasis on the preventive aspects of human disease. Although health authorities generally agree with this thesis, there is need for more precise definition of effective methods and programs of prevention, financial resources required to implement these programs, and priorities to be assigned to research in preventive methodology. The need to assemble expertise in this field to elucidate mechanisms whereby the full impact of preventive medicine may be brought to bear on the solution of America’s major health problems has been expressed repeatedly in public statements by leaders throughout the health field. In response to this need, the Fogarty International Center initiated a series of comprehensive studies of preventive medicine in order to review and evaluate the state of the art of prevention and control of human diseases, to identify deficiencies in knowledge requiring further research, including analysis of financial resources, preventive techniques, and manpower, and to recognize problems in application of preventive methods and suggest corrective action. In an effort to contribute to the educational aspects of preventive medicine, the Fogarty International Center has undertaken a cooperative program with the Association of Teachers of Preventive Medicine to create resource material to assist in the administration, teaching, research, and service responsibilities among departments of preventive medicine, to enhance collaborative activities between departments of preventive medicine and other academic units of health science schools, and to propose national programs of teaching, research, and service in preventive medicine. Topics to be given major emphasis include the role of behavioral sciences in preventive medicine, academic relationships between departments of preventive medicine and schools of public health, international and viii /Prevention in Primary Care

extramural teaching and research opportunities in preventive medicine, teaching resources of departments, health education, primary care and family medicine, the role of ancillary health personnel in the health care delivery systems, and consumer participation in health care delivery.

This monograph on Preventive and Community Medicine in Primary Care is part of the Fogarty International Center Series on the Teaching of Preventive Medicine. The growing emphasis on preventive services has focused attention on the interests and responsibilities shared by practitioners of primary care and pre-

ventive medicine specialists. It is obvious that the knowledge developed in prevention research will be applied in practice through the primary care disciplines of

family medicine, pediatrics, internal medicine and obstetrics. Accordingly, it will be necessary for the educational process to promote the integration of these disciplines with preventive medicine teaching in the development of new knowledge, the delivery of preventive services and evaluation of the health care system. This monograph attempts to analyze ways in which this integration can be accomplished.

Milo D. Leavitt, Jr., M.D. Director Fogarty International Center CONTENTS

Page PARTICIPANTS AND CONTRIBUTORS v A Note from the Chairman Herbert K. Abrams xi INTRODUCTION

William H. Barker xiii RECOMMENDATIONS FROM THE CONFERENCE xxi MEDICAL SCHOOL ASPECTS

Chapter 1 Roles of Departments of Preventive Medicine Jesse W. Tapp 3 INVITED DISCUSSION C. Hilmon Castle 9 DISCUSSION 13 CONTENT AND METHODS Chapter 2 Competency-Based Objectives in Preventive Medicine for the Family Physician Richard M. Baker 23 INVITED DISCUSSION George Thomson 37 DISCUSSION 41 Chapter 3 Preventive Medicine Education in Family Practice Residency Donald Treat 43 INVITED DISCUSSION Rugh A. Henderson 61 INVITED DISCUSSION Gordon Hall 66 DISCUSSION 68 DISCIPLINES Chapter 4 Preventive Strategies, Research and Evaluation in Primary Care Joseph Stokes III 73 INVITED DISCUSSION lan McWhinney 79 DISCUSSION 85 Chapter 5 Community and Social Medicine in Primary Care Leslie A. Falk and F. D. Scutchfield 87 INVITED DISCUSSION F. D. Scutchfield 96 DISCUSSION 99 — —

x/Prevention in Primary Care

Page DELIVERY SYSTEM ASPECTS Chapter 6 Future Organization and Management of Primary Health Care Count Gibson 103 INVITED DISCUSSION William L. Kissick 107 DISCUSSION 109 SUPPLEMENTS Preventive-Community Medicine Roles in Primary Care Education The Family Practice Resident’s Perspective Charles Payton and Stephen Smith 115 Medical Education from the Perspective of Minority Groups A Social Policy Issue Leslie A. Falk 119 Index 123 A Note from the Chairman

The ATPM/Fogarty Symposium on Preventive and Community Medicine in

Primary Care arose from the realization that Primary Care is the most important single aspect in the spectrum of medical care and, at the same time, the most neglected, both from the point of view of training of personnel and in delivery of services to people. Medical care has become fragmented, incomplete and chaotic, and existing knowledge is not being adequately applied for prevention of disease and disability. For at least a decade, leaders in medical education have been calling for increased and improved training of primary care health personnel, both physicians and paramedics. And particular stress has been placed upon the training of a new type of primary physician popularly called the family physician. This physician carries out three major functions: he is the physician of first contact with the patient; he is responsible for maintaining continuity of care; he integrates the care of the patient. In a word, he is the patient’s managing physician. Along with these developments have come new challenges in the training of other primary care providers such as physician’s assistants and nurse practitioners. In addition, in the United States as contrasted with England and most of the Western European countries, there always have been many other kinds of physicians who provide primary care services, such as those in internal medicine, pediatrics, and to a lesser extent, in some of the other specialties. These factors combine to create a sense of urgency in improvement and ratio- nalization of primary medical care training and in the better implementation of team practice to which, for many years, we have all been paying lip service. Simultaneously, the educators in preventive and social medicine have become more conscious of their isolation from the mainstream of both training of medical personnel and delivery of services. The exciting research and discoveries in epidemiology and in preventive medicine are not being adequately exploited either in the medical school classroom or in the doctor’s office. Doctors are graduated from school and go into practice with inadequate knowledge of these vital instruments for better service to the human race. All of this was brought to a head by the approval in 1969 of the 20th specialty of medicine, family practice, and the ensuing renaissance in the development of training programs throughout the country. Very soon many of the “best and the brightest” of the medical students were flocking into the field and within a few years more than 200 approved residency training programs were established and their number is still increasing. The phenomenon indeed reflected a need which finally was receiving long overdue recognition.

The medical schools responded and today virtually every school in the country either has a program of training in family medicine and/or “primary medicine” or is contemplating establishing one.

There is an inextricably close affinity between preventive medicine and primary care. Indeed, primary medical care for the individual and mass community programs are the two stages on which preventive medicine performs. Realizing this, many of the forward-looking people in preventive medicine departments have initiated programs in primary care including family practice training. In many schools, separate departments of family practice have been established. In these instances the separate departments soon realized the need to have components of preventive medicine and family medicine together and either have developed these resources within their departments or created the necessary interdepartmental al- liances to accomplish the same objective. As a result of these varied and complex factors, we see primary care training in the United States taking many forms: training of family physicians, greater emphasis on primary care in the training of internists and pediatricians; and new programs of training non-physician primary care personnel. Reflecting these vary- ing developments are the names of the departments: family and community medicine; primary care; family practice; family and community health, etc.

A century ago Virchow said, “Medicine is a social science, and politics are

nothing else than medicine on a large scale.” Preventive medicine is of the essence

of this social science, yet it is the most neglected area of both medical education and medical practice. Fundamentally, this may be largely the result of the prevail-

ing mode of medical practice in the United States, with its emphasis on disease and on commercialism to a deplorable extent. Yet medical education bears heavy responsibility for leadership to improve the situation.

It is in this context that the Association of Teachers of Preventive Medicine felt

it important to look into the matter of how preventive medicine and primary care training can be most effectively coordinated, and how one can help the other in the development of better informed, and therefore, more humane and effective physicians.

In putting together this symposium, ATPM recognizes first of all the Fogarty Center for its practical assistance in making the symposium possible; secondly, the participants who gave of their time and talent to contribute, we hope, some constructive thoughts on the issues; to Robert Berg, M.D., Chairman of the Depart- ment of Preventive Medicine and Community Health at the University of Roches- ter, who was President of ATPM at the time and gave it his encouragement and to William Barker, M.D., Assistant Professor of Preventive Medicine at the Uni- versity of Rochester, who wrote the excellent introduction, edited the papers and

put it all together. Herbert K. Abrams, M.D. Professor and Head Department of Family & Community Medicine University of Arizona College of Medicine —

INTRODUCTION

Inspection, palpation, percussion and auscultation—diagnosis and treatment time honored attributes of the practice of clinical medicine. In addition to these, what tools and thought processes of preventive and community medicine should be included in the primary physician’s education, hence hopefully in his practice? As depicted in figure 1, this question focuses upon the areas of functional overlap between the fields of Preventive and Community Medicine and Primary Medical Care. The task of this symposium has been to define these overlap areas and to recommend ways to optimally incorporate them into undergraduate and postgraduate medical education. The need for such curricular undertakings has been acknowledged in the fore- most assessments of medicine and medical education in the 20th century. In the introduction to his epoch study Medical Education in the United States and Canada, Abraham Flexner (1910) observed of the practicing physician:

His relation was formerly to his patient at most to his patient’s family; and it was almost altogether remedial. The patient had something the matter with him; the doctor was called in to cure it. Payment of a fee ended the transaction. But the physician’s function is fast becoming social and preventive, rather than individual and curative. Upon him society relies to ascertain, and through measures essentially educational to enforce the conditions that prevent disease and make positively for physical and moral well being.

The Report of the Committee on Costs of Medical Care for the American People (1932) stated in the section on physician education:

Medicine is not an abstract body of knowledge to be used only in a laboratory. It is a social as well as a biological science, and it has economic, psychological, and sociological relationships. The social background and interrelations of medicine should be as much a part of medical education as the physical, chemical, and bacteriological backgrounds. Indeed, this point of view should permeate the entire professional training . . . The content and character of the education given to physicians should focus major attention on those aspects of medical knowledge and technique which in the future will occupy a major part of the time and attention of practitioners. This means, especially greater emphasis on preventive medicine in all aspects of practice, better training in the health instruction of patients, and more attention to problems of mental and social adjustment.

More recently, the Report of the Citizen’s Commission on Graduate Medical

Education . . . Millis (1966), in addressing the training needs of the contemporary primary care physician, noted:

The young physician preparing himself to offer continuing, comprehensive care needs to know people as well as their tissues and organs, medical histories . . . and relationships as well as individual disease states, medical ecology as well as symptomatology. Work in psychiatry would give him some of this background and so would some materials from sociology and public health . . .

Finally, the DHEW Forward Plan for Health, 1976-80 (1974), which identifying prevention and primary care as two major themes for guiding national health policy, stated: xiv/Prevention in Primary Care

Figure 1 . Shaded areas indicate the focus of symposium, the overlap between the fields of Preventive and Community Medicine and Primary Care. Introduction /xv

Primary care is the key to the medical services component of our prevention strategy because most preventive health services are provided on an ambulatory basis through primary care . . .

On reflection, it is apparent that a mix of preventive and community medicine with primary care practice does in fact already exist, and will grow considerably in the future. “Content of practice” studies of general practice (Brown et ah, 1971; Chamberlain and Drui, 1975), internal medicine (Coe and Brehm, 1972; Dowling and Shakow, 1952), and pediatrics (Hessel and Haggerty, 1968), and most recently the National Ambulatory Medical Care Survey (1975), have repeatedly documented that 20 percent or more of tasks that primary care physicians are called upon to perform consist of activities such as well baby care, health checkups, health counseling, immunizations, family planning, etc. The extent to which clinicians might apply concepts and tools of preventive and community medicine is exemplified by the work of such persons as Pickles (1939), Fry (1957), and Hart (1974) in England; and Hames (1971), Robbins (1970), Bjorn and Cross (1970), in the United States. The growing emphasis on preventive services and public accountability in current federal health legislation 1 defines further emerging community-oriented roles for the practicing physician. To effectively carry out the many nondiagnostic, nontherapeutic roles conferred upon them by their patients and by society, the primary physicians need appropriate education in the concepts and application of epidemiology, behavioral science, and biostatistics, as well as selected aspects of economics, behavioral, political, and management sciences. The content and methods for educating future practitioners in these disciplines remain to be determined. A variety of sources (Kane, 1974; Kark, 1974; Morris, 1970; Davies, 1971; Horder, 1972; Breslow, 1976; Alpert and Charney, 1973, and several others in the Fogarty International Center series 2 on the Teaching of Preventive Medicine ) provide extensive authoritative information. To render this material into a curriculum appropriate for future clinicians is a challenge. A recently proposed project to define the preventive/community medicine competencies required in clinical medicine should prove particularly useful for establishing such core educational material (Segall, 1975). Ideally, these educational materials once defined would be integrated into preclinical and particularly clinical phases of medical education. In this regard, surveys conducted by the Association of Teachers of Preventive Medicine in 1973 and 1974 yielded disquieting, if not unsurprising results (ATPM, 1974). While most medical schools reported required course work in epidemiology, biostatistics, medical care, and related disciplines during the preclinical years, very few reported teaching these subjects during the last two, predominantly clinical years when students’ future practice habits are most profoundly influenced. Additionally, few departments reported more than occasional educational input in postgraduate primary care training programs located at their respective medical schools. With the growing national emphasis on developing innovative primary care teaching programs in both undergraduate and graduate medical education, the time is most propitious for incorporating preventive and community medicine teaching far more effectively into this part of clinical training. Against this background the present symposium on Preventive and Community Medicine in Primary Care was convened, under the thoughtful chairmanship of

1 Occupational Safety and Health Act, 1970; Professional Standards Review Organization Amendment to Social Security Act, 1972; Health Maintenance Organization Act, 1973; National Health Planning and Resources Development Act, 1974. 2 New Health Practitioners; Teaching of Chronic Illness and Aging; Consumer Participation in Health Care; Teaching Resources in Preventive Medicine. xvi/Prevention in Primary Care

Dr. Herbert Abrams. Participating in the two-day deliberations were a highly qualified and varied group ranging from longstanding leaders in the fields of preventive, community, and family medicine to residents in training in these fields. In addition to a common commitment to seek rational and equitable approaches to providing health services, individual participants provided valuable perspectives from a number of related areas, including history, sociology, economics, politics, community organization, and education. The contents of the symposium, a series of six primary papers, each accom- panied by formal and informal discussion, have been organized into the following four sections relating to teaching of preventive and community medicine in primary care: Medical School Aspects; Content and Methods; Disciplines; and De- livery System Aspects. Two short essays, which were submitted by special request following the symposium, are found in a supplemental section at the end of the

book. The first is entitled, Preventive-Community Medicine Roles in Primary Care Education—The Family Practice Resident’s Perspective, and the second is entitled Medical Education from the Perspective of Minority Groups—A Social Policy Issue. Each section is preceded by a brief summary, and a set of recommendations

distilled from the proceedings is listed at the front of the volume. The symposium covers in some depth both the conceptual and operational aspects of the stated problem of integrating preventive and community medicine into primary care education. At the conceptual level the section on Medical School Aspects addresses the issue of synthesizing preventive/community medicine departmental activities with those of primary care teaching programs; the section on Disciplines focuses on those aspects of primary care to which epidemiology, behavioral science, economics, etc., might most productively apply; the section on Delivery System Aspects postulates a rational structure for delivery of prevention- oriented primary care services and assesses the societal forces that might bring about such change. At the operational level, the section on Content and Methods of education provides detailed descriptions and analyses of specific preventive/community medicine teaching objectives and methods from several existing Family Medicine Programs. (Note: As the leading primary care teaching discipline in

United States medical schools, Family Medicine is the logical clinical model to

focus upon. However, it is anticipated that the principles and recommendations

contained in this volume might apply to the education and practice of all types of

primary care practitioners—e.g., internists, pediatricians, new health practitioners, etc.)

To summarize and reflect: Is this era when prevention of disease and community accountability, on the one hand, and primary care on the other, are among the leading goals of our emerging national health policy, one discerns in reviewing the subject in these pages, great

potential for these goals to proceed not only in parallel but in consort. It is equally apparent that certain significant barriers must be surmounted in order to optimally achieve such a mix in practice. Not the least among these are the following:

1. The tendency for public and private financers of medical research and education to equate medical progress with development and institutionalizing of new measures for diagnosis and treatment of disease. 2. The tendency in turn for the medical education process to focus almost exclusively on traditional diagnostic and therapeutic roles of the physician. Introduction /w ii

3. The tendency of the medical profession to view its role almost exclusively as that of healing the sick. 4. The tendency for third party financers of medical services to restrict themselves to actuarial models based on the occurrence of symptomatic illness. 5. The tendency of the general public to restrict health concerns to the obtaining of relief from symptoms.

Some of these barriers to preventive and community-oriented medical practice may be surmounted through education of primary care providers, as addressed in this symposium; other of the barriers will succumb only to different kinds of education or persuasion, directed at consumers, elected officials, third party carriers, etc. (Curry et al., 1974; Susser, 1975). Accordingly, it may be hoped that the read- ership of this monograph—students, teachers, deans, practitioners, policymakers, and others—will not only be persuaded of the importance of modifying medical education, but also of the necessity to participate in the modification of other critical factors in the fabric of our health system. To do less would be scarcely to go to sea at all. William H. Barker, M.D. Editor REFERENCES

Alpert, JJ and E Charney 1973. The education of physicians for primary care. DHEW Pub No. (HRA)74-31 13.

Association of Teachers of Preventive Medicine 1974. Newsletter 21:10-14.

Bjorn, JC and HD Cross 1970. The Problem-Oriented Private Practice of Medicine, Chicago, Modern Hospital Press.

Breslow, L (Chairman) 1976. Fogarty International Center Task Force Report on Theory and Application of Preventive Medicine in Personal Health Services. New York, Prodist.

Brown, JW, LS Robertson, J Kosa and JJ Alpert 1971. A study of general practice in Massachusetts. JAMA 216:301-306.

Chamberlain H and HB Drui 1975. Content of care in rural primary health care practices. Medical Care 13:230-240.

Coe, RM and Henry P Brehm 1972. Preventive Health Care for Adults: A Study of Medical Practice, New Haven, College and University Press.

Committee on the Costs of Medical Care 1932. Medical Care for the American People: The Final Report. Chicago, University of Chicago Press.

Curry et al., 1974. Twenty Years of Community Medicine. A Hunterdon Medical Center Symposium. Frenchtown, Columbia Publishing Company, Inc.

Davies, JB Meredith 1971. Preventive Medicine, Community Health, and Social Services. London, Bailliere, Tindall and Cassell Ltd.

DHEW Forward Plan for Health FY 1976-80 1974. US Department of Health, Education, and Welfare, Office of the Assistant Secretary for Health.

Dowling, HF and D Shakow 1952. Time spent by internists on adult health education and preventive medicine. JAMA 7:628-631.

Flexner, A 1910. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. Washington, Science and Health Publications.

Fry, J 1957. Five years of general practice: A study in simple epidemiology. Brit Med J 1453-1457.

Hames, GG 1971. Introduction to Evans county cardiovascular and cerebrovascular epidemiologic study. Arch Intern Med 128:883-886.

Hart, JT 1974. The marriage of primary care and epidemiology. J Roy Coll Phycns Lond 8:299-314.

Hessel, SJ and RJ Haggerty 1968. General pediatrics: A study of practice in the mid-1960’s. J of Ped 73:271-279.

Horder, JH (chairman) 1972. The Future General Practitioner: Learning and Teaching. Prepared by a Working Party of the Royal College of General Practitioners. Lavenham, Lavenham Press Limited.

Kane, RL (editor) 1974. The Challenges of Community Medicine. New York, Springer Publishing Co.

Kark, SL 1974. Epidemiology and Community Medicine. New York, Appleton-Century- Crofts.

Millis, JS 1966. The Graduate Education of Physicians: The Report of the Citizens Com- mission on Graduate Medical Education. Commissioned by the American Medical Asso- ciation. Introduction /x ix

Morris, JN 1970. Uses of Epidemiology. E & S Livingstone Limited, Longman Group Limited.

National Center for Health Statistics 1974. National ambulatory medical care survey: May 1973-April 1974. Monthly Vital Statistics Report 24:1-8.

Pickles, WN 1939. Epidemiology in Country Practice. Bristol and London, John Wrights & Sons, Ltd, Simpkin Marshall, Ltd.

Robbins, LC and JH Hall 1970. How to Practice Prospective Medicine. Indianapolis, Methodist Hospital of Indiana.

Segall, A 1975. Draft proposal for a “Preventive Medicine Curriculum Development Project.” Center for Educational Development in Health, Harvard School of Public Health.

Susser, M 1975. “Prevention and Health Maintenance Revisited.” Bull NY Acad of Med 51(1): 174-243.

RECOMMENDATIONS FROM THE CONFERENCE

These recommendations have been reviewed and approved by a majority of participants in the symposium. They are addressed to those persons who establish and implement health policy. This audience includes:

—Legislators and administrators in Federal and State Governments who write, fund and implement legislation and regulations pertaining to medical education and content of medical practice (e.g., Flealth Manpower Training, Na- tional Health Insurance). —Private foundations concerned with supporting programs in primary care and community health. —Deans and curriculum committees of medical schools in deciding structure, content, and funding of curriculum. —Preventive/Community Medicine, Family Medicine, and other primary care faculty in assessing teaching priorities, content, and methods of their departments or programs. —Medical students, preventive medicine, community medicine, and primary care residents who are concerned with influencing the kind of education they receive. —Consumers who are concerned about the type of physicians graduating from American medical schools.

1. A major role for preventive and community medicine (PM/CM) in primary medical care (PC) should be recognized by all institutions with PC teaching or training programs. Arrangements which facilitate direct involvement of PM/CM faculty in PC teaching programs and research should be strongly encouraged in medical schools and other institutions with such programs. Representatives of the respective fields should actively participate in meetings and other related activities of each other's professional societies (e.g., Association of Teachers of Preventive Medicine, Society of Teachers of Family Medicine, etc.) to facilitate the building of academic bridges between PM/CM and PC. 2. A core set of preventive/community medicine competencies required for contemporary primary care practice should be identified, and optimal methods for teaching these should be developed. Such curricular materials should be developed through the efforts of a consortium of PM/CM and PC teachers and practitioners and professional educators. Such materials should be made available for use by all PC teaching programs and as resource material for setting standards for the PM/CM aspect of PC training programs. 3. The role of PC in providing a full range of basic health services to a community of persons should be explicitly recognized and exemplified by teaching programs. Accordingly, such programs should have the following attributes: (a) Based both in community hospitals or practice settings, and in academic centers where resources and support make it possible to give adequate training in primary care. This will assure adequate visibility of primary medicine in the spectrum of medical care and, at the same time, fully exploit available community and academic resources, (b) Provide ready access to various community agencies and organizations which play important roles in PC (e.g., health departments, school health programs, family planning and welfare services). 4. The important contributions to be made by the disciplines of epidemiology, biostatistics, behavioral science, and selected social sciences to PC service, teaching, and research should be recognized. The usefulness of descriptive and analytic techniques of epidemiology and biostatistics in developing medical record systems and in utilizing these for self-audit, peer review, identification of high risk groups for delivering preventive services and conducting evaluative research, should be recognized and promoted. The important role of behavioral science in understanding and optimizing patient utilization of health services, particularly preventive services, should be recognized and promoted. Political and economic decisionmaking processes should be understood by primary care practitioners to assist them in interpreting and influencing new health legislation and financing mechanisms which affect the delivery of primary care. 5. The need for primary care service administrators with managerial and community health training should be recognized. Appropriate curricular materials and training programs for preparing such individuals should be developed at undergraduate and graduate levels. Departments of PM/CM should take a leading role in this effort.

6. The critical role of health service financing in determining the content of

medical practice and education, particularly as it pertains to preventive and community aspects, must be clearly recognized. The benefits of PM/CM aspects of PC practice in terms of effectiveness and efficiency should be well documented and used to persuade consumers, third party payors, health professionals, and policymakers of the importance of developing positive incentives (professional, economic, etc.) to enhance access to such services. MEDICAL SCHOOL ASPECTS

The symposium opens with a series of formal and informal analyses of the issue of interrelating the teaching of preventive/community medicine and primary care in medical schools. Dr. Tapp relates this symposium to the overall prime purpose of medical school education—to train physicians suitable to meet the needs of society. He focuses on the current strongly expressed need for primary care physicians and the role departments of preventive medicine, with their traditional emphasis on defining and solving health problems from the point of view of the community, can play in this movement. The main body of the paper is a review of current goals and problem lists of preventive medicine and primary care teaching programs in medical schools. Since the two fields have substantial commonality of purpose and institutional needs, the paper advocates a close, if not formally consummated relationship between departments of preventive/community medicine and primary care programs, particularly family medicine. Dr. Castle’s invited discussion agrees with Tapp’s formulation of the issues, but argues for the creation of a new type of community medicine/primary care department rather than attempting to harmonize the ways of the traditional non-clinical preventive medicine department with those of the new primary care. Experience with such a department at the University of Utah is briefly described. Gen- eral discussion begins with an exchange of opposing views on the proposed preventive/community medicine—primary care departmental marriage. An inevitable interlude to establish a working definition of primary care follows. The discussants then address community and preventive roles appropriate to primary care, giving particular attention to the concept and the mechanics of a “trusteeship” between the primary physician and his patients and community. Discussion closes with questions of the distinction between “family medicine” and “family practice” and of the role of these primary care concepts in our changing society.

1 preparation of allied health and physician support personnel, so that physicians and other providers of health services can work more productively together. OF DEPARTMENTS OF ROLES With all of the verbal recognition given to the PREVENTIVE MEDICINE “health care team,” it is still unclear who should lead and who will serve on the team. The role of the medical school in preparing team members seems to be just as confused as the role of the phy- Jesse W. Tapp sician himself within the team. Improved health care teamwork in the community will require more effective learning in the formative years of physicians.

Medical care is being provided to large numbers INTRODUCTION of patients in order to achieve the educational and research missions of medical educators. Providing This paper deals with departments of preventive this care could afford opportunities for research and medicine faced with the current rapidly growing in- development in improving the health care system terest in primary care. Already, a number of medical also. Educational experiences for students in the pa- schools have linked these elements, both in school tient care systems of communities should include

structure and in function. I will review the desirabil- finding ways to expand care in underserved areas.

ity of this development in view of the general pur- Educational experiences in underserved areas

poses of medical education. First, I will look at should be more conducive to entering practice in medical education in general, and then turn to the those areas. Until we put as much effort into the specifics of preventive medicine and primary care, quality of the educational experience aimed at meet- especially as they pertain to meeting society’s ing health care needs as we do into the more eso- expectations. teric aspects of medical diagnosis and treatment, we

Medical school is conventionally viewed as a triad cannot expect to have physicians oriented to com- of education, research and service, with increasing munity service as much as they have been to re- attention currently being given to the last of these. search and subspecialty practice in the past. What responsibility do we in medical education have While meeting the health manpower needs of so- for helping to meet today’s health care needs? We ciety, we are also meeting the career goals of future continually have to explain that, for us, service and professionals, which may be as much of a service to

education are indivisible. Our unique function is to the community as is direct provision of patient care. meet manpower needs for providing health care. To Medical school provides access to becoming a phy- achieve this, the process of educating physicians at sician not only as a traditional middle class career all levels should be focused on the identifiable needs pathway, but now increasingly as a vehicle for mi- of society, both in providing adequate numbers of nority opportunity. We have to be careful, however, physicians and in preparing them with skills and at- that we do not confuse career opportunities for mi- titudes conducive to serving society. Graduate medi- nority students with attempts to meet health care cal education needs to be much more attentive to needs of shortage areas that require another kind of the needs of society for the various kinds of spe- effort for solution. Minority students have no more cialty manpower, as well as to the problem of obligation to help meet the needs of shortage areas geographic distribution of health care providers, by than do any others, but they have potentially great

whatever mechanisms will work. Likewise, graduate sociocultural advantages if they do enter practice in education must prepare physicians for medical prac- the settings in which they know the language and

tice arrangements which are not only cost effective way of life. for society, but also conducive to continuing educa- Scientific exploration continues to be the basis for

tion, focused on demonstrated needs for health care, many health improvements in society, if kept in not just the preexisting interest areas and current perspective along with education and service. Medi-

novelties attractive to physicians. cal faculties conduct research in all three areas of Medical education may also serve society in the their competence, basic biology and chemistry.

3 A/Prevention in Primary Care clinical medicine and community health. More at- These objectives are pursued in a variety of edu- tention is needed for the last; the community ex- cational and service programs. Preclinical courses in pects the institutions it supports to be responsive to the basic disciplines of epidemiology and biostatis- its needs. Medical school responsibility to the com- tics persist in spite of arguments about relevance munity often has been expressed primarily in tradi- and usefulness for most students. Field trips, family tional departments of preventive medicine, and it is studies, home visiting and home care programs are to this area that we now turn for the rest of this used in demonstrating the applications of preventive discussion. medicine doctrine. Learning by doing is popular in student projects and research involvement in epide- DEPARTMENTS OF PREVENTIVE MEDICINE miology and health services. In the past, widespread medical school disinterest in ambulatory care and The long and often distinguished history of pre- outpatient department operations sometimes found ventive medicine in medical education has been well them relegated to departments of preventive medi- documented and analyzed (Grundy and Mackin- cine where they might serve to demonstrate the tosh, 1957; Shepard and Roney, 1964), yet its na- practice of clinical preventive medicine as part of ture and definition are still debated and the necessity comprehensive care. (These ambulatory care opera- for departments as such frequently questioned. In tions now represent money in the bank for those spite of the popular belief that an ounce of preven- departments wishing to express themselves in the tion is worth a pound of cure, the popular purse still new era of primary care popularity!) supports cure far more handsomely. Departments of Graduate programs in preventive medicine are preventive medicine exist in a variety of forms, rang- more common in schools of public health but also ing from being the catchall for whatever is not have been developed as residencies in preventive wanted by other departments to another extreme of medicine or master’s programs in community health being separated from the medical school altogether in a few medical schools, with or without a related as a school of public health. Some feel that depart- master of public health degree. ments of preventive medicine are not needed, be- The problem list for a typical department of pre- lieving that all clinical specialties teach prevention ventive medicine might read as follows: adequately in their own ways, and furthermore that 1 . An appearance of diffuseness, lack of clear epidemiology and biostatistics should be taught by identity or unique contribution in the medical school those who actually apply the fruits of these tools in curriculum (versus the more simply defined content practice. Nevertheless, separate departments of pre- of the clinical and basic science departments). ventive medicine persist in most medical schools. 2. Student unrest and/or disinterest, questioning The educational objectives of preventive medicine the relevance of biostatistics, epidemiology, etc. teaching in medical school may be characterized as 3. Departmental isolation, being neither a pure follows: (1) Doctors should be able to use a null basic science nor being readily accepted as a peer hypothesis in evaluating the statistical significance by the other major clinical specialties. of biomedical data. (2) Doctors should be able to 4. Medical indigency, lacking the cash flow use a denominator in searching for and evaluating which derives from major clinical practices and ac- causes, cures and care processes. (3) Doctors cess to hospital beds. should be able to use the vital and health statistics 5. Inadequate, if any, physical space in the aca- of their population in clinical decisionmaking and demic medical center. problem solving, both for individual patients and for 6. Dependence on community agencies and vol- entire communities. (4) Doctors should be skilled in untary faculty for teaching and research, as well as using environmental and occupational health data service. in patient care and community leadership. (5) Doc- Facing such pernicious problems over the years, tors should know how to use behavioral science some new formulations for preventive medicine tools for understanding and modifying health and have been put forward and have found their ways disease behavior in patients and populations. into departmental designations. “Community Medi- (6) Doctors should understand and be prepared to cine” now claims the most adherents, but confusion participate in the processes of health service plan- has been compounded. ning, organization, and administration. Some define “Community Medicine” to mean Roles of Departments/5 diagnosis and treatment of the community, as if it ately by the design of those who feel that no phy- were a patient (McGavran, 1956; Deuschle et al., sician can competently deal with all ages of patients 1964), giving a unique focus to the community as with all sorts of presenting complaints. (I am the object of interest and work. In this camp, edu- tempted to draw an analogy between our letting gen- cational objectives give emphasis to knowledge and eral practice decay and the origins of the current skills dealing with groups and populations for prob- energy crisis. Society failed to see the impending re- lem solving, environmental control, health education, sult of the overuse of scarce resources. No provision

etc. Educational methods focus on studying entire was made for economically meeting everyday needs, communities with the intention of developing and either of energy or health care. Will society enjoy implementing solutions to defined problems. Personal rediscovering a simpler lifestyle in the same way

health care to individual patients is not generally of that physicians are rediscovering the pleasure of primary concern, and may be actively avoided. taking care of whole people and whole families?) Others interpret “Community Medicine” to mean Now family medicine has emerged as a recognized medical practice in community settings, giving em- specialty defined in terms of breadth rather than

phasis to the health care delivery system. Educa- depth. Though it is viewed by some as being the

tional objectives cite availability, accessibility, ac- jack of all trades and the master of none, many ceptability, equity, and quality of personal health family physicians see themselves going well beyond

care services. Direct concern is expressed with pro- the level of primary care to provide secondary, and

viding health care facilities, funding, medical man- even tertiary care in situations in which they feel

power and teamwork. This orientation is more able to perform. All in all, it appears that hardly sympathetic with meeting demands for sickness care, anyone wants to be either limited to, or excluded

as well as preventive health care. It is also more from, primary care. Everyone would like to have a

conducive to a coalition with primary care providers piece of the primary care action, if it appeals to in the process of delivering health care in such lo- them or meets their economic needs to do so. cations as neighborhood health centers, HMO’s, etc. Other kinds of providers have been getting on the primary care bandwagon, with and without our help. PRIMARY CARE Physician’s assistants are being trained to provide primary care on independent duty, perhaps with Let us now turn to primary care in medical edu- special telecommunications linking them to physi-

cation and explore its relationships with preventive cians for supervision and decisionmaking. The

and community medicine. Especially since the time nursing profession is beginning to take greater in- of the Millis Report (Millis, 1966), increasing terest in primary care, in some places providing di- recognition has been given to educating physicians rect services without any physician involvement.

for providing primary patient care as primary in it- Needless to say, nurse practitioners hotly debate to self, not simply secondary to other specialty training. what extent they are physician’s assistants in primary Among traditional specialists, pediatricians have care. Legislation now defines the extended role of been especially receptive to the importance of pri- the nurse in some situations that do not require mary care, including well-baby and child health physician participation. Patients themselves are be- care. Nevertheless, their doctor orientation to sick ing taught to examine every orifice, with or without care has been frustrated by the preponderance of interpretation of their findings. Self care has always

well children; consequently, the latter care has be- been the most basic form of primary care and still gun to be relegated to non-physicians, especially may be preferable to inappropriate subspecialty

where income protection is not at stake. Internists care. have had much more difficulty clarifying their roles Educational objectives for the teaching of primary as consultants and also as primary doctors for adults. care in medical schools have varied according to the Surgeons, too, continue to offer themselves as pri- setting in which the student has been exposed to primary care providers and in the process have been mary care. The focus usually includes health main- accused of providing twice as much surgery as may tenance, episodic, acute and emergency care, be required by the general population. Meanwhile, psychosocial care, continuing care for chronic illness,

the old-fashioned general practitioner has all but and recognition of other kinds of care for referral or disappeared, partly from neglect and more deliber- consultation. The teaching experience for attaining 6/Prevention in Primary Care such objectives has been variously packaged. Each cording to the American Academy of Family Phy- specialty department has operated its own outpatient sicians, these programs attracted almost two thou- department with the objective of seeing new patients sand graduating student applicants from U. S. and following old patients, before and after hospi- medical schools in 1974. Increasingly large numbers talization, not ordinarily with the objective of pro- of students and potential residents want to be viding either comprehensive or continuing care. trained in this newly defined specialty. The most

Attempts are being made to coordinate outpatient characteristic feature of family practice is the oppor- services by improving systems of communication be- tunity for a single physician to provide care to an tween the different specialty services, and are be- entire family, which is claimed to be more efficient ginning in turn to provide some form of continuing and personal than the usual multispecialty approach. care to patients. Sometimes this chore is delegated Likewise it is claimed that consultation and referral to departments of preventive or community medi- can be minimized and done more readily and effi- cine with the idea that their concern for health ciently when required for some five to ten percent of service organization could result in a workable sys- patient problems. Comprehensiveness and continu- tem. Faculty representing all specialties may func- ity of care are extolled as the primary virtues. It is tion as a group practice and even as a health expected that the family physician will assume the maintenance organization. It is not inconceivable role of leader of the primary care team. The leader- that such organizations could provide comprehensive ship role is not clearcut with regard to the other and continuing patient care teaching models at pri- medical specialties except in those situations where mary, seondary, and tertiary levels without the the family physician controls the flow of patients need for a special primary care organization. Other and income to the other specialists. teaching approaches are preceptorships and other The problem list for departments of family medi- assignments with family doctors, rural practices, cine in medical schools resembles that of preventive outside agencies, charity clinics, and emergency medicine in some respects, adding in their lack of services. specially trained and experienced faculty members.

Combinations of specialists, mainly internists and Family medicine has had to draw its initial faculty pediatricians, are providing primary care learning largely from the preexisting academic specialties, experience for students, sometimes in competition but is now beginning to train its own. The lack of a with family medicine programs, which also offer pri- strong research background is being remedied, es- mary care experience within the same medical pecially in the study of the pattern of illness and the school. Some family medicine enthusiasts prefer to pattern of practice in family medicine and primary remain separate from other primary care providers care. Lack of academic space requires heavy reliance while struggling to gain recognition and legitimacy. on community hospitals and community health care Medical schools have to consider whether or not to facilities and limits the visibility of family medicine grant departmental status to primary care and/or in the academic medical center. In the traditional family practice. If so, what entity will it be? Already curriculum, no time was allocated for family prac- many departments of family medicine have been tice training. However, the plethora of new curricula established, largely in response to political pressure, in medical schools provide increasing opportunity both informally and by legislation. Elsewhere pri- for penetration and reorientation to family medicine. mary care and family medicine programs remain as Lack of hospital beds and Outpatient Department coalitions of ambulatory service facilities with input space have hampered the development of family from multiple departments, or as nondepartmental practice. Lack of recognition by the traditional spe- entities, perhaps attached to the dean’s office. Am- cialties has been helped by the recognition of the bulatory and primary care sections are recognizable American Board of Family Practice and approval of in some departments of pediatrics and medicine. residencies in family medicine. This entire phenom-

The rise of interest in family practice is undoubt- enon is only five years old, and is not yet accepted edly the most spectacular aspect of the primary care as reality by some cautious souls. picture today, beginning with the recognition of The sudden popularity of family medicine among Family Practice as a specialty with American Board students and residents appears to represent among certification in 1969 and the rapid proliferation of other things a widespread desire to return to a sim- over two hundred approved residency programs. Ac- pler lifestyle in more pleasant surroundings. It is not Roles of Departments/1 at all clear yet whether the family unit is really go- In order to provide good primary care, critical ing to be the basis for this practice or whether the selection and evaluation of preventive health care name is not still a euphemism for general practice. measures is required. Otherwise, items of doubtful Certainly the emphasis on the family is the unique validity may be embraced by primary care in the characteristic of the discipline and holds vast po- effort to appear cloaked in prevention. Likewise, tential to reorient thinking and practice, especially preventive medicine enthusiasts require clinical along preventive lines. feedback from primary physicians about feasible forms of prevention and current disease problems. PREVENTIVE MEDICINE—PRIMARY CARE Health services evaluation at all levels can make good use of controlled clinical trial methodology, Departments of preventive medicine have been requiring collaboration of preventive medicine with drawn into the primary care phenomenon and some primary care physicians. This sort of clinical re- have joined forces with family medicine in joint de- search takes advantage of mutual concern for recog- partments. By 1974, 17 of 76 departments respond- nizing the natural history and spectrum of disease. ing to a survey by the Association of Teachers of Both preventive medicine and primary care are Preventive Medicine (ATPM, 1974) were conduct- undertaking the reduction of risk factors and mea- ing family practice residencies. As noted, preven- surement of outcome. Both require community re- tive medicine needs help in strengthening its position sources to achieve the goal of improved health in medical schools and also has resources to offer. status for each patient in the population. Occupa-

Preventive medicine is expected to have the tools tional health is an example of an area in which pri- for the study of health care problems of population mary care and preventive medicine are in practice groups, and primary care seems to be the area in simultaneously with individuals and entire work which to apply these tools. At the same time, pri- groups. mary care needs support. It lacks departmental re- Close collaboration also has risks and disadvan- sources and is not yet widely recognized as a legiti- tages for both preventive medicine and primary mate entity in academia. It is natural for preventive care in the medical school. Areas of antagonism medicine and primary care to join hands to share exist along with synergism. Both have unique mis- resources and pursue complementary goals. sions beyond the areas of common concern. Pre- Educational objectives common to preventive ventive medicine must be able to maintain an medicine and primary care include knowledge and emphasis on the community as a whole, while the skills in the areas of health maintenance, compre- primary care physician focuses on a close personal hensive care, behavioral and social determinants of relationship with each individual patient. One or the illness and management of community resources to other of these emphases in teaching, research, and provide continuity of care. service may be overshadowed by the success of the The advantages of collaboration between preven- other or may be hindered by the failure of the tive medicine and primary care suggest that the other, affecting the performance of both. At the combination can be synergistic. Common educational present time the popularity of primary care and objectives justify taking advantage of student and family medicine has the potential to eclipse preven- physician interest in patient care to help improve tive medicine in the competition for scarce resources the impersonal image of preventive medicine. Com- in the medical school. At a time of disenchantment bination of efforts should provide more efficient use with government and the growing anonymity of of space, curriculum time, faculty, and community mass society, students and teachers may tend to turn resources for teaching. Joint programs can encompass away from the community as a whole to give their the entire spectrum of care from an individual pa- attention to the individual and the family. Never- tient, through his family, on to the entire community. theless, preventive medicine areas such as health If services can be made operational for the entire education, environmental health and disease eradi- spectrum, it should be easier to provide health care cation require continuing strong emphasis on com- intervention at the most effective level. This would munitywide effort. International health programs be true especially in coping with chronic disease become more and more critical as the magnitudes problems where intervention requires dealing with of current world health problems increase. No dim- all age groups and multiple risk factors. inution of effort in these areas can be condoned, 8 / Prevention in Primary Care regardless of how much devotion primary care edu- they can be expected to produce happiness in cation must show to the personal elements of doctor- society. patient relationships, and the excellence of diagnostic and treatment services. Those who want to work with this entire continuum of care from the individual to the whole com- REFERENCES munity must be committed to securing adequate educational resources to perform the whole job. Otherwise the risks of close collaboration may pro- Association of Teachers of Preventive Medicine 1974 News- duce more confusion than success.

letter 21 : 10-14. Having reviewed the current status of preventive medicine and primary care in medical education, Deuschle, KW, HS Fulmer, MJ McNamara and JW Tapp we must consider whether they should follow a com- 1966. The Kentucky experiment in community medi- mon pathway. We do not have firm scientific evi- cine. Milbank Memorial Fund Quarterly 44:9-22. dence favoring joint efforts. This decision must be, Grundy, F and JM Mackintosh 1957. The teaching of like most clinical impressions, based on the judg- hygiene and public health in Europe. Geneva, World ment of those doing the job. Primary care provides Health Organization. good clinical experience in preventive medicine and likewise requires preventive medicine expertise to McGavran, EG 1956. Scientific diagnosis and treatment achieve the goal of health maintenance and com- of the community as a patient. JAMA 162:723-727. prehensive care. Joint and integrated programs are Millis, JS 1966. Report of the citizens commission on now functioning well and thus are possible, even graduate medical education. The Graduate Education of though great care will be required to keep them in Physicians, AMA, Chicago. balance. This combination may work better than the past experience of seeking primary care from the Shepard, WP and JS Roney 1964. The teaching of pre- tertiary care oriented specialties. If preventive medi- ventive medicine in the United States. Milbank Memorial cine and primary care do find happiness together. Fund Quarterly. came too heavy. He indicated his impression that community medicine was superficial, ineffectual, and irrelevant. For example, he described outpatient INVITED DISCUSSION clinics as “inadequate facilities for disinterested faculty to take care of uninteresting patients.” He

clearly felt that Departments of Medicine should not become involved in delivering care to community C. Hilmon Castle populations. With our similar backgrounds of training in internal medicine and academic careers as biomedical

I agree with the problem list outlined by Dr. Tapp investigators and teachers in a subspecialty (he in for Departments of Preventive, Community and Endocrinology and I in Cardiology), after review- Family Medicine in medical schools. They can be ing the urgent needs for improved delivery of care, summarized as: (1) isolation from the mainstream we disagree on the future role of medical schools of student and housestaff teaching and from the in meeting these needs. Unlike Dr. Kaplan, I sub- kind of research that interests academic faculty, and scribe to the definition of community medicine pre- (2) lack of strength and resources to influence and sented by Dr. Tapp, i.e., the identification and affect decisions that will promote Preventive, Com- solution of community health problems, and feel munity or Family Medicine. that medical schools have a responsibility to become My comments reflect my personal experience involved in community problems and their solutions. over the past four years in planning and developing My comments regarding Departments of Preven- a new Department of Family and Community Medi- tive Medicine, Community Medicine or Community cine. In the spring of 1970, I spent three months at and Family Medicine are based on the following a well-known school of public health located in the assumptions: East. My experience there was disappointing since 1. Health Science Centers with their medical it appeared that little was known about how to suc- schools have a responsibility to provide leadership cessfully integrate the teaching of preventive medi- in meeting health care manpower needs, particularly cine, epidemiology, biostatistics, behavioral science, within the region in which they are located. It is not economics, management, health planning, etc., into enough for a Health Science Center to train a suf- the education of the people who would be respon- ficient number of providers; the providers must also sible for delivering health care. The isolation of this be appropriate in type and must be equipped to school of public health from the medical school, as meet the needs of the community. Physicians and well as from the immediate problems of health care other health workers should be educated to partici-

in our country, was quite surprising. I did meet sev- pate in a team approach to delivering health care. eral people who were struggling to acquire the skills 2. Health Science Centers must research health necessary to study community health problems and care needs and formulate and evaluate alternative to incorporate this study into the curriculum for solutions for community health problems. those being trained to deliver medical care. How- 3. Health Science Centers must be able to negoti-

ever, I had great difficulty finding successful models, ate with the people in the community in a mutual inspiration or even direction. quest to provide appropriate solutions to health In an article published in the Archives of Internal problems. Medicine, Kaplan (1972) defined “community 4. Since most medical schools operate on a de- medicine” as the delivery of health care in the com- partmental structure, we must assume we will con- munity (a definition quite different from the one tinue to operate with this administrative arrangement

presented by Dr. Tapp) and noted the advantages for the immediate future. Perhaps this is not the to medical schools in eschewing involvement in the best arrangement, but in established medical schools

delivery of medical care. His opinion was that if it appears to be the only acceptable structure at medical school faculty did become involved in pa- present.

tient care, they should always be in a position to I doubt that the public or even the decisionmak-

opt out of such activity if the service function be- ers in the Health Science Centers perceive a strong

9 10/Prevention in Primary Care need for epidemiology, biostatistics, behavioral sci- vironmental and occupational health, economics, ence, and environmental and occupational health, management, etc. etc. We in preventive and community medicine see 4. Primary Care is first contact care that pro- the need so clearly it is incomprehensible that others vides the patient’s entry point into the health care do not. We will be making a mistake, however, if system. The primary care provider: we do not remind ourselves of the lack of under- a. evaluates the patient’s total health needs, standing of and interest in these disciplines in provides personal medical care within one or medical schools. The terms “Preventive Medicine,” more fields of medicine, and when indicated, “Social Medicine,” Community Medicine” and refers the patient to appropriate sources of “Community Health” provoke a variety of feelings care while preserving the continuity of his and reactions—mostly negative. Even though the care; term “Community Medicine” is becoming more fre- b. assumes responsibility for the patient’s quently used, it still has not proven very helpful in comprehensive and continuous health care, conveying to people outside the field the goals and and acts, where appropriate, as the leader or functions of such a discipline in a medical school. coordinator of a team of health care providers; The similarities among medical schools in their De- c. accepts responsibility for the patient’s partments of Internal Medicine, Pediatrics, Surgery, total health care (preventive, diagnostic, cura- etc., make these disciplines easy to understand but, tive, and rehabilitative) within the context of unfortunately, this is not true for Departments of his environment, including the community and

Community Medicine. For example, if we consider the family or comparable social unit. the enormous differences in the communities that 5. Family Practice is one model for delivering surround Mt. Sinai Medical School and the Univer- primary care. It synthesizes and integrates a wide sity of Utah, we can imagine how different their range of medical and personal skills into the prac- community medicine activities are likely to be. Ap- tice of a single physician. A family physician is one preciating the diversity among those attending this who provides comprehensive, continuous care to all conference, I suspect we will have many differences members of a family. of opinion regarding Departments of Community 6. Family Medicine is a discipline concerned Medicine and their roles and whether they should with the relationship of life in small groups to health, be combined with other departments that have illness and medical care. It focuses on the relation- clinical responsibilities. Ideally, however, it seems ships between the individual (patient) and the fam- that the overall goals of such departments should ilies, and between families and their surrounding be consonant even if their activities vary. environments. As such it represents a continuum of We must define several terms before we proceed clinical medicine with community medicine. in our discussion. It should be noted that these are Traditional departments of preventive medicine not necessarily mutually exclusive. The terms and have not generally played a prominent role in re- their definitions follow: sponding to the perceived needs either of the com-

1. Preventive Medicine refers to a whole spec- munity or of those who provide direct medical care. trum of activities aimed at the prevention of disease. In fact, in many schools disease prevention has been

These may run the gamut from primary prevention better taught by other departments, e.g., pediatrics. (removal of the risk or initiating force) to prevent- The problems of isolation and lack of resources and ing complications of a terminal illness. strength among departments of preventive medicine

2. Clinical Preventive Medicine is the application have sufficiently handicapped them to make them of the knowledge of preventive medicine to indi- ineffective in this area. There is an evident need for vidual patients. An example would be the type of instruction in epidemiology, biostatistics, environ- prospective medicine advocated by Robbins and mental and occupational health, behavioral science, Hall (1970) in the Health Hazard Appraisal or the management and economics for those who will be activities performed in routine well-baby care. delivering health care. The unresolved question is,

3. Community Medicine is the identification and where should these disciplines be located in medical solution of community health problems. This is schools and how should providers of care obtain the medicine of the community and not in the com- knowledge and skills they need? Separation of these munity. It is an academic discipline and includes disciplines into schools of public health has created epidemiology, biostatistics, behavioral science, en- barriers and effectively precluded their access by 1

Roles of Departments/ 1 medical students, housestaff, and medical school —Many outstanding medical school graduates are faculty. I believe if these disciplines are to be taught being attracted into family practice. in the medical school, for their survival they should —Approximately 60 medical schools have devel- be grouped together within a unit that has clinical oped autonomous divisions or departments of responsibilities which relate to the needs and in- Family Practice or Family Medicine and sup- terests of medical students. There must be a better port is being provided to formulate goals and demonstration of the app'icability of these disci- evaluate effectiveness of teaching students and plines to solving problems physicians deal with residents. today and in the future. —Over two hundred Family Practice residencies In order to train qualified health providers in cost- have been established with 1,200 first-year po- effective primary care which is responsive to the sitions for which there were approximately needs of families and communities, we need new de- 2,000 applicants in 1974. partments of preventive or community medicine —Many of the Family Practice training programs which have been sufficiently altered to take on such have the following attributes: responsibility. A department combining community —Learning settings and patients similar to medicine and family medicine and offering a resi- the type qualified physicians will pursue dency in family practice is attractive in some areas, later are being used to provide experi- but perhaps inappropriate in others. Local needs and ences relevant to practice. circumstances are sufficiently diverse to make one —Knowledge and skills in human behavior, reluctant to generalize about such departments. Un- group dynamics and health hazard assess- fortunately, I am not aware of any studies that ment for individuals, families and com- document which arrangement in a medical school is munities are being taught. the most effective in cultivating health providers A good beginning has been made, but the advan- with the knowledge, skills and attitudes obtainable tage of Family Practice over other clinical special- from such disciplines. ties in training physicians to meet the community

As pointed out in Dr. Tapp’s paper, family prac- needs in health care must be demonstrated. If family tice programs have been handicapped because of physicians can be cost effective, I suspect they will their origin outside the academic community. They be sustained on this basis alone. Preferably, if they have been mandated by the legislature in some provide better care with better outcomes as a result schools and by the organized general practitioners of employing principles not embraced by other dis- in others. The conflict between training the “super ciplines, they can be sustained on this ground. doctor” or a new type of physician has not been re- Through a synthesis of family and community medi- solved. Separation of family practice training from cine education, efforts are being made to do the the academic community produces the same prob- following for family physicians: lems encountered by teachers trained in community —Create a system for accountability and feed- colleges rather than universities. The superficiality, back regarding the quality of care provided. triviality, and ossification, emphasized by Silberman —Utilize what is known about families and how (1970) in Crisis in the Classroom, which has oc- this affects the problems they have. curred among teachers trained in community col- —Develop a technology that is unique to Family leges, could be duplicated in the products of family Practice, i.e., classification of patient behaviors practice education. Family practice is still in transi- at the point of contact with physicians and a tion and must become more of a “cerebral” pursuit scheme for classifying interaction between pa- if it is going to have a long life. Family practice tients, families and their environment. education already has great advantages over the Some have argued that primary care and family training previously provided to the general practi- medicine can be practiced well by individuals tioner, e.g.: trained in Internal Medicine, Pediatrics, Obstetrics- —Training is longer and better. Gynecology, or even Surgery. Others have ques-

—Status and a standard of quality have been at- tioned: How appropriate is it for people with such tained through specialty boards in family prac- selective training to engage in the teaching and practice and organizational representation in groups tice of primary care? The family practice model that are making decisions about the future of appears to provide more appropriate training; and

medical education and practice. if principles of community and preventive medicine 12/ Prevention in Primary Care are encompassed in the family physician’s training, pertension detection and follow-up program. We and are within his competence, he should be better have made considerable progress in integrating the prepared to address the current needs in delivery of educational programs in community medicine and care. Internists see themselves as sophisticated per- family practice. Quality of care assessment based sonal physicians and even as a higher quality on process and outcome studies has been possible variant of the family physician. Although this seems because the disciplines in community medicine and a pretentious and unrealistic image, it is one that has family practice have been brought together in the prompted internists to propose that they are the same department. An emphasis on training for com- most appropriate type of physician to meet the petence in our family practice residents rather than health care needs of individuals. relying on amount of time assigned to a specific serv- Individuals in departments of Internal Medicine ice has been maintained as a result of the disci- have noted that support for subspecialty training is plines oriented to evaluation and research. disappearing. Primary care is now in the spotlight Some educators and administrators, who advocate and the public is demanding that medical school re- a new type of primary care physician, feel that en- sources be more effectively used to produce indi- tirely new medical schools are needed. I think the viduals who can provide the necessary kind of medi- job can be done within existing medical schools if cal care. The dominant position of departments of new departments are created, especially if these de- Internal Medicine in medical school makes them a partments include the disciplines mentioned above, logical resource for producing new practitioners. are allotted adequate resources and can depend on Many Internal Medicine departments have more other clinical departments and divisions to teach than one-third of the medical school faculty and the special clinical knowledge and skills that family most success-oriented faculty in the school. Unfor- physicians need, e.g., orthopedics, ear, nose, and tunately, many of them live by the Charlie Wilson throat diseases; office gynecology; dermatology; axiom: i.e., “what’s good for General Motors (in- neurology; etc. Perhaps even existing departments ternal medicine) is good for our country.” It is of Preventive Medicine or Internal Medicine can be doubtful that departments of Internal Medicine effective in meeting the health needs of communi- which have been committed to biomedical research ties, but only if a major revision of goals and faculty and producing the physician-scientist in subspeci- within such departments is effected. The question alties are actually able to provide the kind of remains as to the best approach to gaining the training needed by individuals who engage in pri- strongest commitment of a resourceful department mary care. to teaching and studying primary care. Retrospec-

Whatever the outcome, it would seem to me easier tive analysis probably will not answer the question to form new departments with a commitment of of the most effective administrative arrangement, faculty and other resources to a new purpose rather but studies properly designed and implemented now than redirect departments which have been success- may provide insights as to the best administrative ful in other ventures to training a new type of phy- structures to produce qualified primary care physi- sician for primary care in the 1980’s. Within 4 cians who will help in solving community health years, our new Department of Family and Com- problems. munity Medicine at the University of Utah has established a family practice residency with 36 trainees, certified 54 Medex and deployed them to provide primary care under physician supervision in rural communities, developed and implemented a REFERENCES curriculum for medical students in family and community medicine, developed a residency training in community medicine, developed an ac- program Kaplan, NM 1972. » Community medicine as an academic tive research program in health care delivery and discipline. Fact or fancy? Arch Intern Med 129:124-128.

assessment of quality of care, and instigated several Robbins, LC, JH Hall 1970. How to practice prospective demonstration projects which encompass primary medicine. Indianapolis, Indiana, Methodist Hospital. rural setting, care, i.e., the family health center in a Silberman, C 1970. Crisis in the Classroom: The Remak- model family practice units, and a community hy- ing of American Education. New York, Random House. Roles of Departments/ 13

better understanding of that. As far as management

skills, I wanted to know the economics of running an office: How do you hire and fire people? What’s DISCUSSION necessary to really having an efficient office, etc? I

wanted to know all those things. When I looked at programs throughout the country those were the

things that I was looking for. BAKER: I’m not playing the devil's advocate

CASTLE: There's no question that a knowledge when I say it’s not a natural marriage between de- of epidemiology, biostatistics, behavioral science, partments of preventive medicine and community management, economics, and environmental and medicine and departments of family practice or pri- occupational health is necessary. I agree with Dr. mary care. I don’t see that there’s anything more Tapp that having these things in a school of public natural about that than marrying them with cardi- health has been a mistake. It’s equally a mistake ology or with any other of the major departments. to house them in a medical school department that There is certainly a lot of expertise to offer and a is similarly isolated and unrelated to clinical activi- lot of expertise that we need, and Dr. Tapp has ties. To be authentic to medical students and young pointed this out beautifully in terms of the research physicians, one will have to have clinical care re- capability and evaluation that needs to go on. But sponsibilities. In the problem list for departments of I’m really curious about the consistent requests that preventive medicine, Dr. Tapp said the students are I see for teaching the students preparing for primary questioning the relevance of biostatistics and epi- care. Take environmental and occupational health demiology. They are questioning the relevance of data: It says, “Doctors should be skilled in using everything. I’m not sure I know what they are in- environmental and occupational health data in pa- terested in regarding both clinical and community tient care and community leadership.” Now, it’s roles in electing to pursue a primary care career. hard to disagree with that; but on the other hand,

ABRAMS: Perhaps we could hear from one of you can’t agree with it because you don't know what the residents in response to this. it is. It’s a fuzzy objective that doesn't mean any-

CHRISTIAN: When you come into a program thing as far as what it is that a primary care doctor

like family practice that’s not well defined, you needs to know. I think that instead of dealing with really don’t know what you want. You have a gen- this discipline, preventive medicine faculty, as well eral concept that you want to be the kind of prac- as other specialty faculties, should define for the

titioner that can take care of most problems presented naive people in primary care what it is that would

to you without having to refer out. Basically, it is be important to add to their skills; that is, where the clinical concept. But as far as innovations and interdigitation should take place, but why marriage?

whether or not epidemiology and other community FARLEY: I believe community medicine, pre-

medicine sciences are important, I don't think we ventive medicine and family medicine have a lot in know that. Therefore, faculty concerns about common. All three look at a community. A primary

whether the student is interested in epidemiology care practitioner, whether in general internal medi- are not valid. As teachers, you should be guiding cine, general pediatrics or family medicine says,

the students in the right direction in relation to health “How do I give care to a population of patients?” care system needs. We have a general concept, but Community medicine says, “How do we get health

still the majority of us have come into programs care to a population?” Furthermore, as the primary without clearly knowing what we want and need care practitioner serves a population of patients, he out of the program. starts identifying a community, starts identifying

ABRAMS: What is the general concept? problems of a community and has to pull in a lot of CHRISTIAN: My general concept is that I’m go- knowledge of community and preventive medicine.

ing back to a small community to practice, and I Here is where a close liaison between departments want to be able to take care of 80 to 90 percent of in teaching and research becomes particulary ap- the problems without having to refer out. Also, my parent. As an academic discipline, community

whole attitude about medicine is that you should medicine/preventive medicine, looks at the com-

prevent it before it happens, so I wanted to have a munity from a distance and tries to figure out how \A/Prevention in Primary Care

to get in, how to obtain knowledge of it. The pri- Another point is that family medicine right now mary care doctors are in close, observing the com- is weak, albeit, and it’s weak because the “traditional munity firsthand, as reflected in individual patients medical specialties” want to make sure they don’t and groups of patients. The bias of our program is get their turf usurped, and we ought to speak to that. that if you can train this primary care doctor to or- There’s no reason for a family medicine residency ganize his data so it’s analyzable—then, in addition to be in a community hospital for its inpatient beds to providing for efficient practice management, he except for the fact that the tertiary care specialists may serve community needs through providing don’t want their residents contaminated by primary community medical professionals access to the prob- care. It’s important for us to recognize that. We’ve lems of a community and to the problems of a had to fight like dogs for curriculum time for family population. medicine, much less community medicine. That bat-

There is another area where we can derive mu- tle is going to continue and the traditional medical tual benefit, hopefully. We have never trained ad- specialists will say, “That’s all right, they don’t need ministrators for primary care. Administrators have any family medicine in a formal environment, we’re been developed for hospitals, maybe for some huge giving them a little bit of family medicine in pedi- clinics, but rarely for the needs of health care in a atrics and in psychiatry and they don’t really need community. Preventive medicine and community that.” It’s the same kind of argument that Dr. Tapp medicine departments are beginning to look at this, posed for preventive medicine departments. and hopefully in conjunction with family medicine TAPP: May I comment on the problem that departments, for these are where the greatest re- we’ve already encountered in our program in insist- pository of primary care commitment lie currently. ing that we have a nurse practitioner as a faculty

SCUTCHFIELD: It appears to me that family member and a medical social worker as a faculty medicine and community medicine are two entirely member. They have the same kind of appointment separate and distinct disciplines. Dr. Farley’s re- that the physicians have, and they are presented to marks emphasize this. The focus of community the students and residents as role models as the medicine is the community. Its base sciences deal kinds of people that they should be prepared to work with groups of people. The base sciences that relate with as fellow providers of primary care services. to family medicine by and large relate to individual This is not generally accepted by a lot of the profes- patient care: Medicine, pediatrics, clinical preven- sion to whom we try to respond in the community. tive medicine. Some of our family doctors feel it’s outright com- We need to recognize that these are two separate munistic to have a nurse practitioner working side and distinct disciplines. That doesn’t mean that I’m by side with a family doctor. There is obviously a ideologically opposed to combined departments of great conflict of interest there for some folks. On family and community medicine. Community medi- the other hand, we feel that the ultimate goal is to cine, the older department, has been a logical place have a different kind of worker than what we’ve to start the movement because of its concern with pri- been accustomed to in the past and the only way mary and comprehensive care. We did it because of to model this is by starting at the undergraduate and the press of the sixties, the neighborhood health cen- graduate training levels. But maybe I missed the ter movement, and what not. But we’ve got to spin emphasis you were trying to get at as to whether it off and get back to our responsibility, and our these people, these other kinds of primary care pro- responsibility is the development of community viders, really should be more free to operate in an programs, the development of community resources. open market than they are now. This brings forth a point of disagreement with Dr. They are increasingly operating as separate in- Castle. Development of community programs, com- dependent providers in many parts of the country. munity services, community resources can be excit- FALK: I’ll have my chance when I give my pa- ing to medical students, and I’ve seen it be exciting. per. I might just utter a few words of interdisci- A third of my class in medical school (University of plinary education at the same time, same place,

Kentucky) is in community medicine as a reflection educational exp’eriences among the definitions, the probably of a very strong teacher. It’s important for definition of primary care health team, preventive us to recognize that. levels and those roles which are appropriate as con- : 5

Roles of Departments/ 1

tinuing education with existing backgrounds com- care. If they are already getting it, fine, we’ll just pared to the planned education from the beginning. put it down that they are getting care elsewhere. A

I am talking about the key example, counseling primary care internist essentially says he’ll take a and family focusing, nursing and the strength of the person regardless of sex, disease, or age; and a pri- nursing practitioner with nursing school. mary care pediatrician says regardless of sex or BAKER: Sue Horowitz asked me to mention the disease but limited by age. Then we get into the WAMI (Washington, Alaska, Montana, Idaho) fringe where by default, in reality, OB-GYN people program which is the Department of Family Medi- render a lot of primary care. They are not equipped cine’s effort to provide some experience in primary for it, but they render it because that’s where the care. This is a regional educational program whereby woman goes for her annual physical, and she gets

every medical student who elects the family prac- minor care there. And so I’ll say there, it’s because tice pathway is required to spend 6 weeks in a of sex. In others words, these other primary care

community clinical unit staffed by teams of MEDEX specialties end up with family only if the pediatri-

people. In Washington, MEDEX is our prototype cians, internists and gynecologists are working to- new health professional. gether as a group regardless of age, sex, or disease. PAYTON: Before proceeding further, we need The family medicine practitioner can say as an some definitions of community and preventive medi- individual “I’m concerned or I’m responsible regard-

cine and primary care with which we can operate less of age, sex or disease.” I should say at risk during the balance of the conference. regardless of age, sex or disease.

BARKER: I propose that we focus first on a defi- BARKER: That’s very compatible, I hope, with

nition of primary care and that as we do so we at- what I said. I just felt we shouldn’t allow our working tempt to avoid the family medicine model or any of definition of primary care to get locked into the the several other emerging primary care specialty specific attributes of a particular subgroup of pri-

models per se (e.g., pediatrics, internal medicine). mary care practitioner. Clearly each of these models has particular attri- HALL: Primary care ought to be definable with-

butes, but to discuss all of these is another part of out reference to those who, in fact, provide the care.

the debate. What we need is a broad working defi- I don’t have a definition. I wonder if anyone else has nition of primary care to which we can then address heard of a definition of primary care that excludes our analysis and discussion of the contributions to any reference to that.

be made by preventive and community medicine. McWHINNEY I could answer your question. Furthermore, I propose that we not enter into an This is something we’ve concentrated on recently in exercise to define community and preventive medi- a committee on primary care set up by the local cine at this point. These are vast areas, limited parts health council. The first thing we had to do was to

of which are directly pertinent to primary care. define this, so for what they’re worth, I’ll give you These pertinent parts should emerge in the subse- our definitions. We defined two terms: “Primary quent invited presentations and discussion. health care” and “primary medical care.” Primary

STOKES: That is a very good statement. I agree health care is the care provided by those components with that completely. of the health services which are directly accessible to

FARLEY: I disagree with something Dr. Barker the public. Primary medical care is the care provided said. Basically, I feel that some of the issues of what by physicians who are directly accessible to the pub- is primary care internal medicine, primary care pe- lic. We went on to distinguish between the two broad diatrics and family medicine, do need to be dis- functional categories of primary care professionals

cussed. I propose that the access of family medicine who might provide either health care or medical care:

to the family is not because we’re family specialists ( 1 ) those who enter into a tenured or contractual but because we’ll take care of people regardless of type of relationship with individuals and/or families, age, sex or disease. So we’re exposed to the family not only to be available to them but also to guide and hopefully we develop and use knowledge that them and to accept a continuing responsibility even makes us responsible for the care of all the members after referral; (2) those who deal with problems on a of that family. If one member comes to us, part of more or less episodic basis. Examples would be an

our responsibility is to make sure that others get the emergency room physician or a multiphasic screen- :

16 / Prevention in Primary Care ing clinic nurse who is concerned usually just with PAYTON: Speaking about the way physicians one episode and/or referral out and then the review their community and the responsibility they do sponsibility stops. or do not have for that community, it’s always im-

I suggest that for the purposes of discussing the pressed me that physicians by and large take the roles of community and preventive medicine that we attitude out of sight, out of mind. If it’s not a patient focus on the definitions of primary care which em- that presents him or herself to the office, to the hos- brace personal commitment to an individual for pital, it’s not someone who—for whom he has that continuing care. This is a value judgment, but one I trusteeship responsibility. think we in family medicine would certainly accept. 1 think that is a real problem and it draws into

WALKER: It is a useful suggestion. The question question how we define the contract for a physician. then becomes where do we see the role of manage- Is it a social contract or an individual contract with a ment, prevention, etc., within this definition of pri- single patient, or maybe a patient’s family, if we’re mary care? talking about family medicine.

STOKES: Conceptually, Dr. McWhinney is cor- The way I relate that back now to the general dis- rect. He has focused upon what is commonly thought cussion is that we raise some real issues of contract of as the “trusteeship function,” the idea that one when we talk about prevention of illness because this feels responsible and^ontinuously responsible. If you is not something that is traditionally thought of by the have a patient or a panel of patients, you feel person- patient or the community when they look at the phy- ally responsible for anything that happens in a health sician. way to those patients. That, conceptually, is the nub We have a responsibility in this situation if we look of the issue. at the global effects of health services and try and

GIBSON: I’d like to expand a little upon the recognize their economic values. If we consider that trusteeship issue. As one interested in providing we are “trust officers” for the health of our com- health care, I have found that I could think more munities at large, as would be suggested by those here productively by focusing primarily upon health needs talking about community medicine and preventive and other characteristics of an aggregate of indi- medicine, then we have an education responsibility viduals—aggregated as families, as peer groups, and to make sure that patients come to expect that kind of in a community—rather than beginning a priori with thing from those of us providing primary care. definitions of wholesale medicine and retail medi- FALK: I’m afraid we also have to identify in our cine and so forth. I found these latter to be much too definitions a very uncomfortable borderline between devisive. Accordingly, it's been natural for me to being health professionals and health. I think that think of primary care, family centered and commu- clear examples are the importance of politics and nity centered, as being important concepts. economics to health status. We have to be crisp in There has been a great gulf between what has been our definitions, understanding that health care, par- traditionally public health and traditionally clinical ticularly medical care and what its practitioners can medicine. The clinicians have all been busy with offer, must be clearly differentiated from efforts to everyone who walks in. Public health has tradition- maintain or obtain health for society as a whole. It ally been denied the role as clinician. So we have had gets us into an extremely difficult borderline because many people in our society who, lacking financial, society will tolerate certain things in social change. cultural and other means of access have been without It will look to its priest, doctor, its community a “trust officer” for their personal health care needs. health doctor in certain ways, depending upon the The crucial need in training clinicians in our medical shifting winds of the total socio-political scene. I’m schools is never again to get cut off from a feedback referring specifically to the atmosphere in the civil loop as to where the problems are. Primary medical rights revolution of the 1960’s; the 1968 election; the care education must be community centered, not impounding of Federal funds and the role of the

merely for the panel of families that can keep us very medical student in all of these matters, and how all busy in the model family practice unit, but for all the of these have affected community health.

other people who are there to whom, while respect- THOMSON Somehow or another I am reminded ing their privacy, we have a right to be, an obligation of the girl who said that she wouldn’t sleep with a

to be, accessible. man for $2.00. “What do you think I am, a prosti- —

Roles of Departments/ 17 tute?” He said, “Well, will you do it for a million ment. They, as physician advocates, tried hard to bucks?” She said, “Well, that’s a different thing.” He raise the Mississippi Delta area up economically, to said, “It’s already defined what you are, now we are change the social and physical environment, to act as just bargaining for price!” This is fundamentally what health officer within the area, and so forth. They had we are doing here—it’s not so difficult to define a to fall back. That is, they learned the limitations of primary physician. It shouldn’t be difficult. You health services as an operational basis for that type could just go and look at what my dad did in his of intervention. This is why I object to putting pri- practice because he was the primary physician. He mary care in the position where it’s really encom- was the only physician so that made it easy. You passing the classical functions of public health and could tell what he did and you can define that. other functions of government, as exercised through

Our problem here is that we are trying to build a the police power of the state. definition that refers to the process of the delivery of McWHINNEY: I would agree with that. How- primary care in a complex modern society. Now, are ever, it’s a mistake to try to erect a sharp dividing we trying to define the credentials of the primary line there. I’d rather see it as a spectrum. As you physician, or content of primary care, or are we try- start at the primary care end of the spectrum, you ing to define the process of it? We’re not really hung have a physician who predominantly relates to indi- up on the definition of the primary physician or viduals. But then responsibility gradually extends what is primary care, but we each have our different outwards to the family, and to the practice as a group, levels of what we’ll buy or what we’ll pay for as far which is a fairly new concept. Extending beyond as what the process of delivery is about. Does this this, one encounters responsibility to the community divisiveness make a difference so far as reaching a as a whole and then to the country and the world conclusion for defining this? eventually. The ways in which the physician inter-

SCUTCHFIELD: I would disagree to a certain venes to solve the kind of problems that Dr. Stokes extent with Dr. Thomson because we’re trying to was talking about are quite different from the ways circumscribe the scope of primary care, and the com- he goes about solving his individual patient’s prob- ments that Drs. Gibson, Payton and Falk have made lems. And so, I would see the people at the two ends are valuable in delineating and delimiting the trustee- of this spectrum as really having rather different roles ship concept—the trusteeship not only for health and attitudes. One is primarily a personal physician. care, but also for health within the community. It’s The other is primarily a health care administrator. important that we define this as a part of primary They share certain basic sciences with which to fu'- care. And that, incidentally, reflects a real role that fill their responsibilities to those they serve. Epide- community medicine has to play in impressing what- miology contributes to both and it should be looked ever student or trainee, educator or educatee of their on as underlying both. responsibility, not only for health care but also for I was rather intrigued by something a veterinary health. They must assume this trustee responsibility. epidemiologist in our department of epidemiology

STOKES: There is a real argument developing said to me, which pinpoints our problem. He said here and I want to come down against some things that he found in teaching veterinary students he had that have just been said or implied. If I were respon- no difficulty making them think in terms of the herd, sible for preventing disease in a community, I would but with medical students he had great difficulty mak- not have a job since society has not worked primarily ing them think in such population terms. This is part through the health services route. It’s not the most of the challenge I am facing with family physicians efficient way of preventing disease. Environmental those physicians who are actually physicians for indi- intervention by public health, by housing, by high- viduals but have also this capacity for thinking and way design and environmental design are really more functioning in terms of the herd. important and have a greater impact on life expect- ABRAMS: The prototype of the physician in ancy from birth, infant mortality and other major whom all of this is called for is the individual family health indices than have health services. Jack Geiger doctor in a rural community. He’s also the parttime and colleagues showed very well the limitations of health officer. He’s responsible for everything. There health care services as a means of influencing the are quite a few of them and quite a few places that health effects of the social and economic environ- need people like that. :

18 /Prevention in Primary Care

HENDERSON: I originally drifted into public their setting, and the families are probably the most health through a situation like you just described, crucial part of the setting. It’s not the only part. and then when I got into more complex situations There are other aspects to the individual’s social working in public health, I found that I was not sup- environment; for instance, his work group and his posed to be concerned about individuals anymore, community. which was very upsetting. ABRAMS: Would you say that on occasion “fam- ABRAMS: Before closing our discussion of ily” may be a community, or a factory group, or definitions, I would like to invite comments on Dr. whatever?

Castle’s distinction between family medicine and FARLEY: Economically it can be, but I would family practice. hate to be an industrial physician and say I was tak-

McWHINNEY I agree with Dr. Castle’s dis- ing care of families. tinction between the two; that is, family medicine as ABRAMS: But most industrial medicine in this a body of knowledge, and family practice as a method country is done by general practitioners or family for providing primary care. One source of this body practitioners. of knowledge grows out of a conceptualization of FARLEY: Right, but it’s not family medicine. It’s what practitioners have been doing for a very long different—I won’t include that in my family medi- time and have learned to do unconsciously just by cine definition. trial and error. KISSICK: The rest of you are quite informed and CASTLE: I have a problem accepting such con- have read and written in the area under discussion. ceptualization. I really question whether there is I’ve reflected some on it, mainly at the prodding of much of the ideal of good family medicine to be our dean because he was under great pressure from found in “family practice” as it has existed in the the legislature of the Commonwealth of Pennsylvania past. to organize a department of family practice. As I

CHRISTIAN: Agreed, because if you limit your listen I have two concerns: First, is around the family. concept to someone who takes care of anybody re- It appears to me that we are struggling with a 1980 gardless of sex, age and disease, you don't promote problem with a 1950 vocabulary, and we’ve got to the concept of looking at people as part of families. be truth oriented. Most of us are medical educators, In selecting a family practice residency, I was spe- and the medical students we are now selecting will cifically concerned with providing health care to reach the middle of their professional careers, if they small groups, namely the family. However, I really are not wiped out by myocardial infarctions, in the don’t see why there is such a distinction between year 2000. Even though I’m a long range planner, family practice and family medicine. that staggers me! I don't know what’s going to hap- GIBSON: I’d like to reinforce this distinction. I pen to the family over those decades, but from the find it a fruitful one. There has been an enormous limited reading that I've done of Warren Bennis in deficit of research and study of the family in health. the Temporary Society and Beyond Bureaucracy as And there are many, many kinds of disciplines that popularized by Alvin Topler, the family may not need to be concerned. Perhaps one can say that the exist as an institution, as a social institution as we family practitioner has more crucial need for research now know it, in the year 2000 and beyond. in family medicine than anyone else among the clini- Is the family an enduring concept? It’s been here cians. But a specific prerogative or monopoly should since biblical times. It keeps evolving. Maybe it’s not be implied. For instance, at Stanford, the social going to be a lot different than the way we define it workers are doing very beautiful research on family and study it at the present time. If we’re really in- medicine and health as it relates to the parents of terested in family medicine we have to put great children with leukemia. These social workers are do- emphasis on the sciences basic to understanding some ing something informative to all of us. The internist, of these kinds of problems. the subspecialist, nfeeds to hear it as well as the family The next question is, does it make a difference? practitioner. The few published studies are somewhat discourag-

McWHINNEY I wonder if putting all our em- ing—most of all, George Silver’s study at Montefiore phasis on the family isn't a bit too restrictive. The Hospital where they gave superb comprehensive, essential difference between the family physician family-centered medical care with a team of superb

and the specialist is that he sees people as a whole in health professionals—and I make that last statement Roles of Departments/ 19

advisedly because I worked with those people. There it we’re functioning under the assumption that it was absolutely no difference between the control does, and it may. I hope it will, but it’s incumbent group and the group that was receiving comprehen- upon us to demonstrate that it does, and if not, to sive health care. modify it.

But does it make a difference? If we’re advocating

CONTENT AND METHODS

This section, in two parts, reviews experiences of several existing Family Medicine programs in developing content and method of preventive/community medicine education for primary care. Dr. Baker outlines a core set of learning objectives in preventive/ community medicine for medical students and residents preparatory for family practice. The objectives, developed by a multi-disciplinary faculty committee at the University of Washington, are subdivided into competencies in the domains of knowledge, skills, and attitude. Dr. Thomson’s discussion endorses the competency-based methodology for defining skills and knowledge; however, he cites several potential shortcomings of the system. First, systematic learning tends to limit the student’s conceptual range. Second, the system needs stronger emphasis on developing preventive attitudes. Third, cognitive facts may become irrelevant as medical knowledge advances. Solutions to these perceived shortcomings are discussed. General discussion focuses first on the issues raised by Dr. Thomson. This is followed by suggestions that both consumer demands and measures of health care outcomes should be used, along with physician performance in delineating educational ob- jects for primary care. The discussion concludes with several statements regarding the potential for medical school to effect attitude change. Dr. Treat’s paper describes the type of educational resources and methods conducive to effective preventive/community medicine education in primary care training programs. Examples are cited from the University of Rochester’s Family Medicine Program. Dr. Henderson’s discussion compares and contrasts point by point the primary care educational milieu at the Pennsylvania State University College of Medicine at Hershey with that in Rochester. Dr. Hall’s discussion provides a third model vis a vis preventive/ community medicine education, that of the Rockford (Illinois) School of Medicine, based primarily in existing community practice settings. All the authors establish the importance of a community setting for primary care education. Some participants, however, emphasized the danger of isolating primary care training when confined only to community hospitals. They expressed the need of assuring a prominent place for primary care within the medical school

if it is to be visible to the student, if it is to benefit from the prestige of

21 22/Prevention in Primary Care

the school, and if it is to be effective within the power structure of the institution. The brief general discussion addresses the critical issue of financing for both education in and delivery of community-based, preventive health services. Limitations in current third party and prepaid plans are noted, and the potential for governmental or private corporate actions

to overcome these is pointed out. 2 and community medicine.* Though most of the document can be related to preventive medicine defined

broadly, those objectives most directly related to it COMPETENCY-BASED OBJECTIVES are reported in the main section of this paper. We IN PREVENTIVE MEDICINE FOR have based these upon the arbitrarily defined “core THE FAMILY PHYSICIAN competencies” of the family physician successfully completing our postgraduate (residency) training

program. Our initial list of objectives was generated in a series of three meetings of fulltime faculty in Richard M. Baker the Department of Family Medicine. This draft was then modified by input from family physicians in the community and in rural areas involved with the teaching program and by faculty of other depart- Family medicine, a burgeoning new discipline, is ments. Subsequently, residents and medical students beginning to define itself. Preventive medicine and have assisted in modifying the objectives. Last, we community medicine are clearly a part of any family have found some objectives too ill-defined or trivial practice. Teaching competencies in these fields to remain, and we have added others that have be- should serve to modify the primary care delivered by come apparent in the two years since initiation. the graduates of family practice programs. In this Many objectives are most appropriate for the un- sense we now have a great opportunity to influence dergraduate curriculum. The Department administers delivery of primary care in the United States. We a Family Physician Pathway for medical students must, therefore, carefully define the knowledge, during their clinical years. Seminar topics from the

skills, and attitudes of preventive and community course “Preventive Medicine in Primary Care,” medicine in relationship to the “ideal” future family taught conjointly with the School of Public Health

physician. faculty, appear in Table I. Other objectives are ap- The definition of preventive medicine competen- proached in the required clerkship in family medi- cies for primary care establishes the framework for cine at rural sites or in clerkships or electives in developing educational objectives, teaching strate- other departments. gies, and evaluation methods. Such a process of Residency training seems the appropriate time for

definition is in contrast to the older, more casual the achievement of most objectives in community

attitude of suggesting, “Why don’t we have them take medicine and practice management. It is only then a course in the School of Public Health?” or, “Com- that the trainee has acquired enough confidence in munity medicine ought to have some seminars.” his basic medical skills to devote attention to the “Competency,” in this approach, refers to an ob- “process” of family practice. Faculty members assess servable ability in an area, such as preventive medi- resident performance in areas of community medi-

cine. It seems to be formed by a combination of cine and practice management utilizing a question-

knowledge, skills, and attitudes (Mager, 1962). The naire which appears in Appendix I, this chapter. competencies defined by different training programs “Health maintenance” can be audited on the charts may well be quite disparate until we are able to of residents by following such a flow sheet as illu-

demonstrate that the proposed abilities enhance pa- strated in Appendix II, this chapter. tient care and/or physician satisfaction. Two levels The process of modification of our stated objec- of competencies are likely to emerge—those common tives underlines the need for making and writing to any good family physician and those to be them down. Students, residents, faculty members of achieved according to individual practice plans and Family Medicine and other departments have utilized interests. the objectives heavily in their curriculum design and The Department of Family Medicine at the Uni- * Persons who contributed to the development of these ob- versity of Washington has established “Competency- jectives are: Drs. DJ Bone, MA Browder, DK Clawson, WM Based Objectives for the Family Physician,” (Baker Cole, WB Howe, JR Jacobs, JA Lincoln, RM Oakes, TJ & Gordon, 1974) including objectives in preventive Phillips, CK Smith, WC Stolov, and RV Twerslu. M.S.W.

23 24/Prevention in Primary Care

TABLE I. Conjoint 462—Preventive Medicine in Primary 2.0 CLINICAL MEDICINE Care 1 2.1 KNOWLEDGE SEMINAR TOPICS: 2.12 Disease Information The scope of preventive medicine For minimum competency in managing dis- Geller Tables and health hazard appraisal ease, the family physician must have sufficient Hypertension knowledge of common diseases and uncommon Cancer of the cervix but important ones to permit diagnosis and Diabetes treatment or referral. “Disease” for the family physician includes not only conditions due to SUGGESTED TOPICS FOR STUDENT physical stress, but those due to psychosocial PROJECTS: stresses as well. “Uncommon but important” SCREENING FOR SPECIFIC DISEASES diseases are those that must be understood be- Bacteriuria cause of potentially serious consequences that Tuberculosis may be averted or postponed (e.g., glaucoma, Breast cancer diabetic ketoacidosis) or because the disease Cancer of colon and rectum should be understood as a model of a patho- Glaucoma physiologic process (e.g., muscular dystrophy, Syphilis/gonorrhea systemic sclerosis, cerebral palsy). Knowledge Coronary artery disease (diet & exercise) of any given disease should include: Lung cancer 2.121 Prevalence (approximate, including Prostatic cancer populations at risk) OTHER TOPICS 2.122 Manifestations at various stages Screening in pregnancy (rubella, Rh factor) 2.123 Diagnosis (including hazards of pro- Effectiveness of the screening physical exam cedures) Automated multiphasic screening procedures 2.124 Natural course, including approxi- Factors in patient compliance mate morbidity and mortality rate Seat belts 2.125 Complications Genetic counseling for selected diseases 2.126 Effective interventions Nutrition 2.127 Preventive measures Environmental hazards (smog, heavy metals, 2.15 Evaluation of Preventive Measures All of medicine can be considered preventive asbestos, pesticides, etc.) since most actions are taken with the expec- Obesity tation or hope of averting worse disease. Immunizations However, the term has come to refer rather spe- Alcoholism cifically to diagnosis and treatment the Smoking while patient is as yet unaware of illness. In the ab- Drug abuse sence of symptoms, the physician is totally

1 responsible for what he initiates. He is not, as in Elective course developed and taught by Dr. Ann A. Browder and Dr. William M. Cole. responding to needs also perceived by the patient, protected against deficiencies in the state of the art of medicine. He must be able to evaluation. Objectives in preventive medicine and identify and evaluate available measures before community medicine make relatively concrete and launching a program of prevention. The follow-

finite what are sometimes considered amorphous ing questions are the most cogent for the logical fields. The following sections in outline form are the approach to the discharge of this responsibility: objectives most closely related to preventive medi- —Has the disease a morbidity/mortality that cine as excerpted from the “Competency-Based Ob- makes it an important one to prevent? The jectives for the Family Physician” (Baker, 1974). more serious the potential illness, the lower The numbering corresponds to that of the complete the prevalence needed for the disease to be document. considered important. Competency-Based Objectives/25

—Can one detect one of the following stages preventive procedures. An example set of forms of the disease process? may be seen in Appendix II. -A risk exists? 2.231 Occupational medicine -The disease is present but asymptomatic? 2.231.1 Assessment of common risks

-The disease is present with minimal symp- 2.231.2 Injury prevention techniques toms? 2.231.3 Evaluation for work “fitness” —Is the detection procedure such that: 2.231.4 Management of industrial com- -the sensitivity and specificity (the number pensation cases of false negatives and false positives) are 2.232 Immunization—accepted schedules acceptable? and techniques

-it is acceptable to the patient? 2.233 Risk evaluation—e.g., using Geller -the cost and risk of test are reasonable in Tables relation to the yield? 2.234 “Screening” procedures—See “Diag- —Does intervention at the point of detection nostic and Preventive Procedures,” make a difference in the morbidity/mortality Section 2.24, and “Evaluation of Pre- of the disease greater than that which can be ventive Measures,” Section 2.15.

exerted when symptoms are most easily ap- 2.24 Diagnostic and Preventive Procedures preciated? 2.241 Office laboratory procedures: uri-

-Is it reasonable to accept the risk of inter- nalysis, urine acetone and bile; vention for the gains anticipated? hematocrit; white blood cell count; —Is the intervention acceptable to the patient differential; peripheral blood smear; and will the patient comply with the regi- sedimentation rate (Wintrobe Meth- men? od); throat cultures, sensitivities; 2.23 —Are resources such that: Gram stains; tests for pregnancy; -follow-up of positive screening tests and mono spot test; microscopic evalua- subsequent intervention can be carried out? tion of vaginal discharge, urethral dis- -the proposed screening and intervention are charge, skin scrapings. the best use of available resources? 2.242 Audiometry and visual testing 2.2 SKILLS 2.247 Pap smear

Health Maintenance Skills 2.2422 Tonometry For individuals and for the practice, the 2.2424 Pulmonary function testing— FEV, family physician must develop a program to VC, MEFR maintain health and prevent disease. Standard 2.25 Treatment Procedures procedures should be woven into the system to In the following lists we try to enumerate

ensure availability of all indicated measures to procedures and some management skills that

all patients at risk. Members of the health care should be a part of the family physician’s mini- team must be able to maximize compliance by mal repertoire. patients with recommended procedures and 2.254 Rehabilitation management schedules, consistent with the attitude of respect 2.254.1 Evaluation of a disabled patient for the individual’s own responsibility. Health and his environment in order to

maintenance is the anticipation of problems determine the need for a special and appropriate action in situations of risk to rehabilitation center and the abil- individuals of known physical, sociocultural, en- ity to solve the problem with the vironmental, and emotional make-up. There- local community resources. fore, one may advise breast exams, or even 2.254.2 Prescription of basic physical mammograms, every six months on a woman therapy and occupational therapy with a strong family history of breast cancer, or for common ambulation prob- one may spend more time than usual preparing lems and pain and motion prob- a given child for elective surgery. Health main- lems. tenance forms display the history and plan of 2.254.3 Use of behavioral principles for 26 /Prevention in Primary Care

modification of problems in problems with job, relationships, maintaining function; chronic feelings. pain, use of drugs. (d) Aged: isolation, retirement, feel- 2.254.4 Management of disabled indi- ings, loss of function viduals involving the family home (e) Couples: communication, sex, situation, visiting nurse, and other other interpersonal problems community resource persons. (f) Family: communication, role prob- 2.255 Obstetrical management lems, management of problems in 2.255.10 Clinical assessment of pelvic one member, newly emerging pat- adequacy terns of family life 2.255.12 Fetal monitoring 2.258.8 Anticipatory guidance: This skill 2.255.14 Prenatal care stems from sensitivity to poten- 2.255.16 Post partum care tial stresses because of the spe- 2.255.17 Genetic counseling cial nature of the stress (hyster- 2.256 Management of newborn infant ectomy, child leaving home, 2.256.1 Immediate care in delivery room etc.) or of the individual of normal infant 2.258.9 Patient education: ability to in- 2.256.2 Detection of acute and life- form patients in an appropriate threatening problems (tracheo- manner, language, and detail esophageal fistula, diaphragmatic about their problems from the hernia) physician’s point of view and 2.256.4 Detection of neonatal problems about the physician’s plans and during transitional phase (first expectations four hours of life) and later 2.258.10 Self-knowledge: cognizance of phases: respiratory distress syn- own attitudes, problems and dromes, transient tachypnea, strengths in dealing with other recurrent apnea, infections, persons. Ability to act in an ac- hemolytic disease, jaundice, cepting, objective manner with metabolic abnormalities (hypo- sensitive or difficult topics calcemia, hypoglycemia), CNS (deaths, sexuality, “deviance”) abnormalities 2.3 ATTITUDES 2.256.5 Management of common prob- 2.37 The prevention of problems should be lems of the premature infant: sought whenever possible; risk should be monitoring growth and nutrition, evaluated and minimized when feasible physiologic handicaps for the individual patient. 2.257 Gynecologic management 2.38 Patient education should be carried out 2.257.2 Abortion—ambulatory patient to whatever level is appropriate. 2.257.3 Contraception counseling 2.257.4 1UD insertion 3.0 PRACTICE MANAGEMENT

2.257.5 Diaphragm prescription and fit- ting 3.1 KNOWLEDGE 2.258 Behavioral management 3.11 Legal Aspects of Family Practice 2.258.5 Counseling 3.111 State and national regulations: re- (a) Children and parents: rearing prac- porting communicable disease (VD, tices, school problems, discipline, hepatitis, etc.); premarital exams; responsibility preschool exams, neonatal proce- (b) Adolescents: sex, school problems, dures; food handlers’ screening; peer relationships, substance abuse qualifications for driver’s licensure; (drugs, medications, alcohol, cig- informed consent; sterilization and arettes) abortion permission; obtaining court (c) Adults: obesity, substance abuse, orders for treatment; commitment Competency-Based Objectives/27

3.244.6 procedure and other mental illness Flow sheets problems; mental incompetence. (a) Health maintenance 3.118 International travel requirements for (b) Management of common problems immunizations —hypertension, diabetes, etc. 3.14 Roles of Health Personnel 3.245 Data recording—dictating, computer Understanding training, competencies and 3.246 Recall system: “tickler file” roles of nurse practitioner, physician’s assistant, 3.247 Clinical audit for: patient care, con- office nurse, nursing assistant, technician, social tinuing education, management, re- worker, physical therapist, medical secretary, search. Example: Patient Care Ap- receptionist, pharmacist, dietitian. praisal

3.2 SKILLS Set criteria for “quality” manage- 3.23 Team Approach to Patient Care ment 3.231 Sharing responsibility for patient care Pose questions for chart review with another health professional: the Identify charts degree of sharing will vary widely ac- Review (by clerical personnel cording to the competencies of the ideally) health professional (nurse practi- Collate data tioner, Medex, Primex, Physician’s Evaluate Assistant, etc.) Alter practice if necessary 3.232 Cooperation for patient care with 3.248 Transfer of information to: third- others in the medical care team: office party payers, consultants, hospitals, nurse, nursing assistant, secretary, other primary care physicians, Public other assisting personnel Health Department 3.233 Conjoint management of patient 3.3 ATTITUDES problems where indicated with other 3.31 The physician’s professional role must be physician, social worker, counselor, planned into available time, consistent psychologist, public health nurse, with other commitments, especially the physical therapist, dentist, pharma- family role. cist. 3.32 Tasks and responsibilities should be 3.24 Clinical Records shared among coworkers and other health 3.241 Problem-oriented methods: problem professionals.

identification, problem list, ambula- 3.33 A medical practice should provide care

tory follow-up notes, hospital prog- that is available geographically, finan- ress notes, use of records by all mem- cially, and temporally.

bers of health care team. 3.34 Since it is impossible to understand a pa- 3.242 Filing and retrieval system: Morbid- tient in a single encounter, he should ity Index (Coding—ICDA, RCGP, ideally be observed and followed up over etc.), age/sex, geographic distribu- a prolonged time period. tion, others 3.35 A medical practice should facilitate ap- 3.243 Data collection devices: question- propriate use by as much of the commu- naire, interview by office personnel nity as possible by making the procedures 3.244 Data compilation and display and environment acceptable to persons of 3.244.1 Chart system wide age range, cultural and racial back- 3.244.2 Clerical information ground, and socioeconomic classes. 3.244.3 Data base 3.36 The physician’s practice should facilitate (a) Family structure and health his own happiness. (b) Past history (c) Personal and social history 4.0 COMMUNITY MEDICINE (d) Physical examination 3.244.4 Laboratory values Community Medicine has as yet no fixed defini-

3.244.5 Medication records tion because it is such a wide-ranging field. The term —

28 /Prevention in Primary Care may be used to designate all those aspects of the Maternal and child health organization of practice which impinge on the de- Mental health livery of care, the relation of the practice to its com- Communicable diseases munity, locally and nationally, and the relationships Community resources of a variety of factors within the practice to each 4.122 Visiting Nurse Association (usually other (also see “Practice Management,” Section 3.0). fee-for-service) The family physician must integrate his practice so Assessment of home for nursing that resources available for health maintenance, care disease prevention, and medical care delivery give Home nursing care the best care possible to the most people, to those Home health aid within the practice and the community at large. He Physical therapist needs to know the community in two ways—as the 4.123 School health—often Public Health composite of health resources and as an entity itself, Nurse paid by the school district requiring prescription and care. 4.124 Community Mental Health Center

4.1 KNOWLEDGE (if available) government supported 4.11 Health needs of the community, both objectively plus fee-for-service and as community expectations 4.125 Social Services 4.111 Perceived needs by community The following agencies are peculiar groups, individuals to the State of Washington, particu- 4.112 Health planning: national priorities, larly to the Seattle area. Most will state emphasis, regional “comprehen- have counterparts in other areas. sive health” planning body (usually 4.125.1 State Department of Social and

for one or several counties), and local Health Services is a super-agency community plans and desires. encompassing several divisions: 4.113 Evaluation by physician: data neces- (a) Division of Public Assistance sary to plan involvement and im- Aid to Families of Dependent provement in community health. Children

4.12 Health Resources of the Community General Assistance 4.121 Public Health Department (Old Age Assistance, Blind As- Traditional provision: sanitation con- sistance, and Disability Assis- trol (water, milk); environmental tance shifted to Federal Govern-

quality (control of pollutants); col- ment January 1, 1974, under the lection of vital statistics (birth and SSI Program [Supplemental Se- death registration with compilation of curity Income])

corresponding rates, including infant Services for all the above cate- mortality); surveillance of disease gories remain with the State: frequency and investigation of epi- Medicaid, food stamps, chore demics; care of the indigent. services. Recent trends: provision of direct (b) Services for the blind provide medi- medical care to special groups in the cal care, rehabilitation and voca- community (such as persons eligible tional services. for maternal and infant care or chil- (c) The Division of Vocational Reha- dren and youth clinics, selected mi- bilitation serves handicapped per- nority groups) or care for specific sons who have potential for becom- conditions (VD, family planning, ing employable. tuberculosis). Screening and follow- (d) (Health services are listed above.)

up of chronic diseases is increasingly 4.125.2 State Employment Security pro- done (hypertension, cervical cancer). vides assistance in procuring jobs; Public Health Nurse: unemployment compensation. Basic health teaching 4.125.3 State Department of Labor and 3

Competency-Based Objectives/29

Industries processes industrial is a listing in the telephone di- claims; provides a rehabilitation rectory. Social workers and psy- center. chologists in private practice are 4.125.4 Private agencies included. (a) American Cancer Society—trans- (d) Division of Public Assistance pro- portation to medical appointments vides some counseling services for cancer patients; patient educa- through Family Services, Adult tion services; sick room equipment, Services, CPS (Children’s Protec- hourly nursing services. tive Services). (b) American Red Cross—short-term (e) Hospital social workers and chap- emergency assistance for service- lains men and assistance to victims of (f) Counseling with Vocational Reha- natural disasters and fires; services bilitation and Services for the to aged. Blind (c) Easter Seals Society—provides ap- (g) Legal Aid and Lawyer Referral pliances, rehabilitation equipment, Service (Bar Association). orthopedic shoes; Information and (h) Schools—principals, counselors, Referral Service. teachers, psychologists, nurses and (d) Salvation Army Welfare Services social workers Bureau meets many unmet commu- (i) Red Cross provides counseling for nity needs, e.g., emergency assist- servicemen and their families; aged.

ance for food, lodging, medicine, (j) Lay groups—Alcoholics Anony- counseling. 4.125.6 mous, Weight Watchers, Planned (e) St. Vincent de Paul—social serv- Parenthood, smoker’s clinics, pre- ices section provides emergency natal classes, drug rehabilitation assistance and counseling. groups, etc. (f) Jewish Family Service—provides Other local resources limited financial assistance and Migrant health, Indian Health counseling. Service, National Health Services (g) Volunteer services organized by Corps, Regional Medical Pro- church groups—provide transpor- gram projects, etc. tation for medical appointments, 4.126 Referral resources emergency assistance. Consultants (h) Service clubs and fraternal organi- Medical Center

zations may provide help in spe- Special resources: regional com-

cific situations. prehensive health planning agen- (i) Crisis agencies—local groups to cies should have files on available provide crisis assistance and re- resources for special problems, ferral. such as blindness, speech and hear- ing problems, mental retardation, 4.125.5 Counseling resources renal failure, muscular dystrophy, (a) Family Counseling Service, as well congenital disorders, leukemia. as church affiliated agencies (Cath- 4.127 Medical emergency resources fire- olic, Jewish, Lutheran, Unitarian, — men, police, rescue agencies, military etc.). Check telephone directory 4.128 Nursing, rehabilitation facilities “yellow pages” under “Social Serv- 4. 1 Beneficial and harmful influences upon ices.” Fee based on ability to pay. health, illness and medical care in the com- clinics. (b) Community mental health munity: demographic characteristics (em- Fees based on ability to pay. ployment, age, race, income) and environmen- (c) “Counselors—personal problems” tal hazards (pollution, industrial hazards). 30/Prevention in Primary Care 4.17

4.14 Elements of Hospital Organization and Rela- Community communication network and dis- tionships aster plans 4.141 Tripartite hospital system of govern- 4.2 SKILLS ance: rights and obligations of board 4.21 The assessment of one’s own expectation of trustees, medical staff, hospital ad- from the community and the ability to ministration. choose suitable living arrangements and 4.142 Staff by-laws: Selection and approval lifestyle. procedures, qualifications, restric- 4.22 Integration of practice into the commu- tions. nity to improve health care and satisfy 4.143 Key personnel: administrator, board personal goals. of trustees, medical staff officers, 4.23 Effective relationships with other health business manager, director of nursing resources in the community. services, laboratory director. 4.24 Influence in a community for improve- 4.15 Elements of Organization of Skilled Nursing ment of health care and of related pro- Facilities cesses. 4.151 Ownership: individual, partnership, proprietary corporation, non-profit 4.3 ATTITUDES corporation 4.31 The assumption of responsibility for pro- 4.152 Nursing home governance: adminis- viding health care in a community. trator, board of trustees (except in 4.32 Acceptance of the community’s lifestyle individual or partnership-owned and the role of the family physician in the nursing homes), director of nursing community. services, medical review board. 4.33 The understanding of community re- 4.153 By-laws governing operation of facili- sources as an integral part of the health

ties—administrative and patient care care system; cooperation is essential in a policies. joint effort to maintain the health of the 4.154 Key personnel: administrator, board community, prevent disease, and care for of trustees (where applicable), busi- problems. ness manager in large facilities, direc- In summary, we have found that our initial at- tor of nursing services, social worker. tempts to codify the knowledge, skills, and attitudes 4.155 Physicians’ services required: admis- of the family physician have yielded rewards in vir- sion to skilled nursing or rehabilita- tually every aspect of our educational effort. Though tive care only upon recommendation much refinement and frequent changes need to be of physician and patient remains carried out, the joint statement of objectives pro- under care of a physician. Medical vides an openness of purpose and a commonality findings and orders must be made upon which to organize the educational effort. available to the facility prior to or at the time of admission. Patient information includes current medical status, diagnoses, rehabilitation potential; summary of courses of prior REFERENCES treatments and orders for immediate care of patient. Patient’s total program of care to be reviewed and re- Baker, Richard M and Michael J Gordon 1974. Compe- vised by attending physician at least tency-Based Objectives for the Family Physician. Asso once every 30 days. for Hosp Med Ed. 7(2) :2— 16.

4.16 Organized Medicine in the Community Mager, Robert F 1962. Preparing Instructional Objec- 4.161 Medical societies—local, State, National tives, Fearon Publishers. APPENDIX I

Family Medicine Resident Performance Evaluation 2 The following items are excerpted from the three-page questionnaire filled out by all full-time faculty members for each resident quarterly. The rating scale is specified on the questionnaire and space for comment is provided.

PART I BASIC SCIENCE SKILLS AND ATTITUDES— APPROACH TO PROBLEMS

PART II CLINICAL SCIENCE A. Clinical Science Knowledge Understands principles of clinical physiology and pathology Demonstrates knowledge of common and otherwise important diseases Demonstrates knowledge of clinical behavioral science (human development, behavioral disorders, psychiatric disorders, psychiatric intervention, psychosomatics) Demonstrates knowledge of clinical therapeutics Demonstrates knowledge of preventive medicine (concepts of epidemiology, evaluation of recommendations for detection and intervention) B. Clinical Science Skills

Demonstrates skill in guiding patients through health care system (appropriate referral to other health resources, maintenance of communication, coordination of care) Demonstrates ability to implement an appropriate health maintenance program for patients C. Clinical Science Attitudes Sets realistic goals in management of patient problems

Maintains an attitude that help should be attempted for all patients Takes a broad view (physiological, behavioral, social) of patient problems Shares responsibility for solving patient problems with the patient, including adequate patient education Maintains a preventive attitude

PART III PRACTICE MANAGEMENT A. Practice Management Knowledge Demonstrates understanding of the training, roles, competencies and effect on practice of non-M.D. office personnel B. Practice Management Skills Demonstrates skill in management of clinical records (use of P.O.M.R., dictation filing and retrieval, transfer of information to consultants, hospitals, etc.)

3 Constructed by Michael J. Gordon, Ph.D. 32 /Prevention in Primary Care

C. Practice Management Attitudes Shares responsibilities appropriately among co-workers Emphasizes follow-up and continuity of care Appropriately allocates personal and professional time APPENDIX II

FAMILY MEDICAL CENTER HEALTH MAINTENANCE NAME University of Washington RECORD DATE__

/ 20-40 Yrs. 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

Cardiac PE

Fundoscopic

Cholesterol

CXR ONE TIME

Pulse Assessment ONE TIME

HCT ONCE IF NOT PREVIOUSLY DONE

Rectal & Stool Guaiac ONE TIME

PPD ONE TIME

Urine Dipstix

VDRL ONE TIME WT |a|111 Dental PE |||

Interval hx form IiimImm 33 FAMILY MEDICAL CENTER HEALTH MAINTENANCE NAME University of Washington RECORD DATE

Fundoscopic ONE TIME

Cholesterol

CXR ONE TIME

Pulse Assessment ONE TIME

HCT

Breast PE

Pap. SM.

Rectal & Stool Guaiac ONE TIME

PPD ONE TIME + PRENATAL

Urine Culture

VDRL ONE TIME

Gonorrhea Culture

Dental PE DT

Interval hx form WT

34 FAMILY MEDICAL CENTER HEALTH MAINTENANCE NAME University of Washington RECORD DATE^

> 40 Yrs.

Cardiac PE

Fundoscopic

Cholesterol

CXR

Pulse Assessment

ETT

Rectal & Stool Guaiac

Urine Dipstix

PPD

Urine Culture

VDRL

Dental PE Tonometry DT

Interval hx form

35 FAMILY MEDICAL CENTER HEALTH MAINTENANCE NAME University of Washington RECORD DATE

Breast PE

Pap Sm. c Bimanual Pelvic

Rectal & Stool Guaiac

Urine Dipstix

36 ,

In Vol. II of the 1878 British Medical Journal, it

is repeated three times that the trouble with women

becoming physicians is that they too closely follow INVITED DISCUSSION the dictates of their professors. That is, it was felt that women were easily trained but could not be educated. (Forgive the Victorian error about women.) George Thomson Do you consider yourselves as being well trained, or do you believe you are well educated? As a trained person, you know that b follows a. As an educated person, you know why b follows a. To My first comment on Dr. Baker’s paper—I wish paraphrase Michael Shimkin (1971): I had said that! Let me quickly give an encapsulated summary as I see it because if I didn’t see it right I In war as in medicine, the well trained say “Can do.” may be agreeing to the wrong thing. My summary of The well educated asks, “Should we do?” While we his paper is that the objectives are in the field of need both good training and good education, the knowledge, skills and attitudes. Then: (a) set the competency-based objectives by Dr. Baker seem to objectives, (b) give the experience, (c) identify emphasize the training. The major questions to be those not met, (d) recycle to ensure objective ob- solved in the proposed program are the Sackett-like tained, and (e) reevaluate to ensure all have suc- questions on evaluation of screening procedures ceeded. (Sackett, 1972). These goals are important and the system efficient.

When a system is absent, real problems will arise. AN ATTITUDE DIRECTION On my Canadian Licensure Examination, I faced HAS NOT BEEN MET just five questions on internal medicine—one was Through competency-based objectives, there is an about gout. I must have missed all lectures on gout. excellent emphasis on knowledge, and why to ac- I had never seen a patient with gout. I found nothing cumulate it. After all, one learns best under the pres- in my four years of class notes on gout. I had never sure of moderate anxiety—and if you don't learn learned anything about gout! That was at once a this, you flunk! Skill is learned when you recognize tragedy for me and a potential travesty on the public that for right-handed people, the right hand is dom- which I would serve. Baker’s system would probably inant. But, has there been an effective pedagogical have prevented this tragedy and travesty. tool developed which teaches attitudes? However, I am left with three major concerns, for What is attitude? From the American Heritage which I need HELP! These concerns are: ( 1 ) Learn- Dictionary that Dirty Dictionary which defines all ing of a system delineates concepts; (2) Attitudinal the four letter words you might have wondered about: direction has NOT been met; (3) Cognitive facts “A state of mind or feeling with regard to some may not be relevant (i.e., competency-based objec- matter.” Your attitude, then, is a state of mind which tives are based on the assumption that the goal is focuses your thoughts and affects your behavior. agreed upon but an agreement may not be true or (I’ll apologize in advance. I got out of the service correct, e.g., remember, in 1950 to be certified as an and started Medical School the next day in Canada. obstetrician, a competency-based objective was to Many of my classmates were ex-pilots and artillery give 100 mgm of Diethylstilbestrol daily to a patient officers. H. L. Mencken said for four letter words with a threatened abortion!) look to Canadian troopers or Neapolitan boatsmen. LEARNING OF A SYSTEM DELINEATES My attitude toward four letter words changed in that CONCEPTS environment and my behavior may reflect it. So, what the hell, let’s talk about teaching of attitudes.)

This is not bad. Learning of a system, a protocol, To sell me a new attitude, it has to have: (a) A

an algorithm, a standard workup, a health mainte- practical size I can carry in my head, not in a book,

nance procedure is good. But learning by such a pro- (b) I can easily see it does some good, (c) It is

cedure prescribes thought. something so believable I can use it day or night, (d)

37 38 /Prevention in Primary Care

When I use it, it works, (e) It will help me help use develops a “preventive attitude.” See example in others. Table 1. In attitude teaching in Preventive Medicine, Baker has tended to follow Hilleboe’s (1965) model of: COGNITIVE FACTS MAY NOT BE RELEVANT (a) Prevention of Occurrence (b) Prevention of

Progression (c) Patient Education. We may well question some of our experiences. Is I propose that Thomson’s 3X3 problem-solving there a value in doing Pap smears? Kinlen and Doll matrix is easier to use. My model is not new, only (1973) just finished doing a rehash of the data in in its daily application to clinical problem solving. It British Columbia. It again raises the question of what is a combination of the Epidemiologic Model of happens as the result of doing all these Pap smears. Host, Agent, Environment, and the three levels of It has increased the number of hysterectomies done prevention: Primary, Secondary, Tertiary. in British Columbia but has it affected deaths from

The advantages are: (1) it provides an easy carcinoma of the cervix? formula to remember; (2) it requires consideration to Multiphasic screening raises another question. fill in or reject filling in; (3) it provides a manage- When you consider that there is a calculated five ment tool to patient problem solving; (4) it can be percent false positive error for each test and you do applied to all clinical problems; and (5) its constant an SMA-16, you are getting almost to the point

TABLE 1. Prevention Matrix prepared for a problem of a 75-year-old woman with a fracture of the wrist.

HOST AGENT ENVIRONMENT

Maintain nutrition and vigor in all No appropriate preventive Promote senior citizen centers to elderly. measures found. encourage physical activity and better nutrition. Primary Preventive Warn patient of brittle bones and Wear non-skid shoes Promote better lighting, smoother Measures prone to fall Decrease weight if overweight walkways which patient might Teach to fall correctly use. Wear wrist bands when walking on ice

Hormone supplements

X-ray all sprains No appropriate preventive Provide transportation for injured Carefully select anesthesia measures found. Insure trained personnel available Secondary for care Preventive Measures Cast in cock-up position, mobilize Removable protective splints Check for irritation from cast, early, keep fingers active. after cast removed, to be allergy to plaster, firmness of

worn in daytime. fit.

Complete Medicare reports.

Active and resistance exercises for Patient protected from falling Adequate facility and appoint- fingers and elbow. again. ment for rehabilitation, transportation, payment of costs. Tertiary Preventive Measures Program of better health mainte- No appropriate preventive Educate family and/or nursing nance to prevent recurrence measures found. home personnel about increased risk for recurrence of accident Competency-Based. Objectives/39

TABLE 2. Abbreviated Statement of Criteria for Programs was described by one of my residents as “giving of Multiphasic Screening (after Sackett’s Com- the benefit of your best guess.” mittee Report to APHA, 1969) 2. Specific Protection

I. Screening must lead to an improvement in end results Get your Tetanus and Diphtheria shots so you among those in whom early diagnosis is achieved: won’t die. But neither has an effect on creating a) Therapy is effective. a herd immunity. Polio vaccine probably does. b) Diagnostic confirmation is available. But where does herd immunity fit in our criteria c) Compliance by asymptomatic patients can be achieved. for specific protection? d) Long term benefits to patients will outweigh detri- B. Secondary Prevention: "diseased” or “at high mental effects to those labeled 1. Early diagnosis is a good thing. In some in- risk.” stances it only helps you worry longer about e) Effectiveness of each component is proved before your disease, but at least you know what you being added to a multiphasic system. are suffering from. is possible conclu- II. The cost-benefit and cost-effectiveness characteristics of That one the program of screening and long-term therapy must sion you can draw from the data that life expec- be known: tancy after age ten has not been prolonged in a) The frequency and severity of the disease warrants the past 20 years. an action to detect it. 2. Management of patients to lessen the se- b) The effectiveness of a screening test should relate to the population screened. verity of their complication is fine. But, if long- c) The probable level of use of the information by the term steroids and immunosuppressants are not

screened population should be known. decreased, we’ll kill ourselves with superinfec- mix of screening tests should be appropriate for d) The tions or old fashioned T.B. the target population. C. Tertiary Prevention:

1 . Rehabilitation—is it always good? Let’s get some criteria which will help us evaluate post- that where—think of it this way, wait until they get operative remedial exercise for a metastatic hip new machine, SMA-21! fracture in a 75-year-old woman with emphy- This reminds me of my father-in-law’s experience. sema. Let us look at this from a cost/benefit Among his many useful inventions he had one which standpoint as well as a caring standpoint. excelled. He designed a low cost little tool which 2. Terminal Care—I don’t know if any of you looked like a pair of pliers. With it you could easily have read my descriptions of primary, secon-

repair the buttons on shoes. It was ready for market dary and tertiary prevention. I always add con- just as they quit making high button shoes. siderate terminal care to the tertiary level. Look

These experiences suggest a need to develop a set at criteria in reference to this because it may be

of criteria to assess what we are doing. And, gentle- that here is where we can get the greatest payoff

men, this is why I am here. My hidden agenda is to of anything in the field of prevention. When we get you to help me develop a set of criteria for what prevent problems for a five-year-old child in we are doing. I had hoped this conference could at adjusting to having lost his grandmother, the least deduce these. For the Section of Epidemiology effects of how that is done may last 70 years for of the American Public Health Association (APHA), that child.

David Sackett ( 1969) prepared some criteria for the At this point I am going to ask a question. How

field of screening for early diagnosis. (See abbrevi- many of these “good things” will emanate from pro- ated statement in Table 2.) But, is early diagnosis fessors of preventive medicine and how many of the only level of prevention in Primary Care? Is them are actually going to be coming from the pri- early diagnosis the only thing we do? What about mary physician in his day-to-day care of patients? It developing criteria for assessment of all levels of seems that our responsibility as teachers of preven-

prevention? tive medicine is to teach preventive medicine in a

A. Primary Prevention: primary care clinical setting and we might find it

1. Health Promotion and Education more effective. Keep out of drafts, drink your prune juice, wear I will conclude with the following: (1) Teach

galoshes, brush your teeth twice a day and see knowledge and skills per Baker's paper. I think it is your dentist twice a year. This type of education excellent; (2) Consider a way to get some deep, in- —

40/Prevention in Primary Care grained attitudes of prevention into all students Hilleboe, HE and GW Larimore 1965. Preventive Medi- cine. Philadelphia, Saunders. whether they be primary care types or not; (3) Let WB the experts gathered here develop a set of criteria on Kinlen, LJ and R Doll 1973. Trends in mortality from how to evaluate what is relevant. The primary physi- cancer of the uterus in Canada and in England and Wales. cian wants this help—and he isn't getting it. Br J of Prev and Social Med 27:3.

Sackett, DL 1972. The family physician and the periodic REFERENCES health examination. Canadian Family Physician 18:61.

Shimkin, Michael B 1971. Report from Laputa. Arch

British Medical Journal 1878. Volume II. Environ Health 22:151-153. : :

with Dr. Thomson’s point that it may be very con- stricting. SCUTCHFIELD: Despite the limitations of the

DISCUSSION method, it’s important for us to develop competency- based behavioral objectives in order to get any kind of handle on the quality of our educational product.

It is difficult to define the attitudinal objectives,

but all of us are aware of the experience, I’m sure, of having seen the family physician who has effec- McWHINNEY That was a very thought- tively demonstrated that he has that attitude which provoking presentation. However, when talking to you regard as a preventive attitude. And if you can new residents coming into our program, I talk about identify what it is that he did that led you to know these three or four areas in a different order. I put that he had that attitude then you can come back and values and attitudes first for several reasons. First, put that into your behavioral objectives. This argues because they are the fundamental thing that we’re for task analysis of the model family physician with trying to change. If we change the values and atti- that preventive attitude. I would further support ef- tudes, then the teaching of appropriate skills and forts to establish Magerian behavioral objectives be- knowledge will follow. Secondly, I think they are cause the exercise producing those educational ob- more durable because certainly the knowledge will jectives in and of itself allows the faculty to focus turn over every few years. Thirdly, because they are their philosophic efforts towards the production of a so much more difficult to teach. In fact, one can’t common educational product— it makes the faculty teach values and attitudes in any formal sense. This focus on what it is that they want to convey to the makes the setting and the role models absolutely student. vital. In other words, if the values and attitudes that FARLEY: I would like to further reinforce the we’re trying to convey don’t pervade the whole setting point that among competencies to be taught the prac- of education and are not practiced by the teachers titioner is the attitude and ability to be critical of then we might as well not talk about them. what he is doing, to ask questions saying, “This is the

Further reason why the setting is so important is way I do it now, but is it right?” Maybe ten years that it’s not until the student or resident confronts from now we’ll change our whole system of looking the problems that he’s able to learn how to deal with at cervical smears or examining breasts or whatever. them. It’s so very different learning something in The practitioner needs an attitude to adapt and con- theory and then coming up against a problem and tribute to such change. This may be reinforced by looking for solutions to it. This is one of the problems encouraging practitioners to play a role in develop- we’ve encountered in teaching epidemiology to resi- ing data on which decisions regarding such change dents. are based. In relation to skills, some are uniquely suited to S. SMITH: Dr. Farley points out that much of family practice. Among these are the tactical and what we’re being taught might be irrelevant in 10, strategic preventive medicine skills to be used by a 15, 20 years, and that the practitioners should be pre- family practitioner. [Note: these are discussed in de- pared to change ideas about what is right and what is tail in Dr. McWhinney’s paper in chapter 4 of this wrong. One way to get that done is through the feed- book.] back from one’s patient population. Accordingly, you My last comment would be one of sympathy or can’t consider a family medicine resident to be com- empathy with you in writing Magerian objectives petently trained unless the training has included first- because they become less and less possible and mean- hand experience with consumer feedback and con- ingful as you go up the scale. When you’re down in sumer responsibility for the definition of the needs the practical scales it’s easy. The more you get on to and for the planning and evaluation of the services attitudes, values, and philosophical levels, the more rendered to meet those needs. This important con- difficult and impossible it becomes. I was comforted sideration has been missing from the discussion so to read in Silberman’s Crisis in the Classroom a far. critique of the Magerian approach to educational ob- CHRISTIAN I have some reservations on this

jectives. While it’s valuable as a discipline, I agree point. In my residency training we have worked with

41 42 /Prevention in Primary Care

consumer advisory groups and frequently found that social environment there that sustains and supports they don't have a realistic approach to what is cost this preference? effective. They want you to manage many more pa- BAKER: There are three major reasons why tients than you can. They want you to create more many students graduating from the University of facilities than you can. So my point would be that if Washington are heading for primary care, particu-

you are going to train residents to work with con- larly in rural areas. The first is the admissions pro-

sumers, that you counsel them to assess how well in- cedure which is in part the result of a State school formed the consumers are regarding how much medi- responding to a clear social need, at least in the cine costs, what services are available, effective, etc. Pacific Northwest. The admission committee looks Part of the resident’s role, in fact, might be to assist hard for students who are going to do that. If you ask

consumers in becoming better informed. me how they look for them, I don’t know the answer.

PAYTON: I would like to pursue this further (It is a standard saw that is classic in senior skits and suggest that in delineating educational objectives that you can’t get into the University of Washington’s we ought to begin with outcomes of the health care Medical School unless you say, “I’m going to be a system—getting people, physicians as well as con- rural family doc in the Pacific Northwest.”) sumers, to think about what it is that we would like Secondly, the modeling system has changed. Family

to have accomplished through this massive multi- Medicine, through its involvement in core curricu- billion dollar effort that we’re putting forth. This lum, puts on three half-days of the orientation week focus on the primacy of outcomes on the part of during which we introduce the concepts of inter- practitioners ought to create an attitude conducive to personal communication. We do it in small groups achieving the competencies Dr. Baker has listed. with physicians, mainly family docs that are on the

Also, starting with outcomes, you will speed the faculty, and these are the first doctors the students

learning process in medical school, f note that Dr. see. The subspecialist is no longer the prime or sole

Baker has listed under knowledge, for example, clinician model. Lastly, there is a very successful “Prevalence, approximate, including populations at curriculum advisory system for students who are pre- risk.” Now, I can remember my pathology textbook paring for primary care. This includes ongoing con-

always having a little section about males greater tact with both academic and community-based than females occurring in the third decade, etc., etc., family physicians.

but I couldn't understand why I needed to know that The curriculum for the pathway fits Whitehead’s

at that point. Okay, if we could start with the point conceptual frame, beginning with a romance phase that we have outcomes to achieve and one of those the first year—communicating with patients; pro- outcomes is the prevention of illness, maybe we can ceeding to a precision phase during the second year show students, both at the undergraduate and the —critically discussing preventive medicine and other postgraduate training levels, why they need to retain primary care skills and concepts in seminars and that piece of information. Motivation! Get them to learning the application of specific skills in consort recognize that this is for the benefit of their patients. with a practicing family physician; and concluding On the matter of creating the community/preven- with a synthesis phase consisting of a six-week semi- tive attitude, T would like to take us back one step nar clerkship in a family practice in a rural com- from the discussion of training to a consideration of munity.

the attitudes we are starting with in students entering STOKES: I question the implication that basic the medical fields. To what extent do these entering values and attitudes can be taught in medical educa- attitudes determine the ultimate attitude of the prac- tion. Basic attitudes and values derive from the

titioner? 1 understand that an unusually large pro- family and from earlier training and cultural experi- portion (approximately 50 percent) at the University ences. All we can do in medical school is reinforce of Washington Medical School elect to pursue the those attitudes which we consider good. “Family Physician Pathway,” a curriculum which, SCUTCHFIELD: Wrong! Members of my medi-

in title at least, implies a philosophy very different cal school class received a Multiphasic Personality

from most of the training I received in medical Interview every year for four years: We got para- school. I am interested in what accounts for this. Is noid, lost our humanitarianism, got authoritarian, there something about the students that are selected? lost our social conscience, and became very disease Is there something additionally different about the focused. They certainly changed our attitude! 3 ence. Since this type of physician would need an amalgam of skills not customarily found in the products of any existing residencies, new training pro- PREVENTIVE MEDICINE EDUCATION grams would have to be launched. In 1969, when IN FAMILY PRACTICE RESIDENCY the new field of family medicine received specialty status by virtue of the establishment of the Ameri- can Board of Family Practice, there were only a handful of residencies to train the new practitioners. Today, there are over 287 approved residencies, Donald F. Treat over 85 departments or divisions of family medicine in American medical schools, and several dozen in other countries. Concurrently, there was a great surge INTRODUCTION of activity among legislative and philanthropic bodies to provide essential funds for the support of With the publication of the Millis Report (Report these educational efforts; and a few of the traditional of the Citizens’ Commission on Graduate Medical specialties, particularly pediatrics and internal medi- Education, 1966), the attention of the medical com- cine, began to rethink and reevaluate their own ap- munity was abruptly shifted from the comforting proach to medical education at both graduate and scene of leaping advances in basic biomedical re- undergraduate levels in light of expressed public search to the disquieting spectacle of serious opinion and changing priorities. deficiencies in the health care delivery system. A Out of this ferment the outline of a new breed of major emphasis in Dr. Millis’ report was that the physician is gradually appearing—one dedicated to system would function much more efficiently and bringing high quality of care to the common health economically if each patient had access to a primary problems encountered in daily living. One can then physician who would be responsible for advising, define, for purposes of this paper, the primary care coordinating, and supervising the patient’s medical physician as one who: ( 1 ) serves as physician of first care. Another national commission (National Com- contact with the patient and provides a means of en- mission on Community Health Services, 1966) try into the health care system; (2) evaluates the pointed out that the direction in medical education patient’s total health needs, provides personal medi- would need some alteration if personal physicians cal care within one or more fields of medicine, and were to appear in any number and be equipped to refers when indicated to appropriate sources of care provide high quality of care. The Willard Report while preserving the continuity of his care; (3) as- (Meeting the Challenge of Family Practice, 1966) sumes responsibility for the patient’s comprehensive enunciated the necessity of special training for phy- and continuous health care and acts, where appro- sicians who would both deliver primary type of care priate, as leader or coordinator of a team of health to patients at easily accessible points of entry into care providers; (4) accepts responsibility for the the medical care system, and be responsible for pro- patient’s total health care within the context of his viding logical continuity and supervision. environment, including the community and the During the same years that these committee re- family or comparable social unit (DHEW, 1973). ports received national prominence, the American While the family physician, as primary care physi- Academy of General Practice (later changed to cian for the family, regards the health of the whole American Academy of Family Practice) vigorously family— all ages and both sexes—as under his aegis, advocated the concept of the family physician as one at least on the primary care level, the other major which would meet the need for comprehensive, con- deliverers of primary care—the internist, the pedia- tinuing care. The family physician would be broadly trician, and the obstetrician—customarily place cer- knowledgeable in the medical disciplines most useful tain limitations with regard to age or sex of their to physicians of first contact—internal medicine, pe- patients. diatrics, preventive medicine, obstetrics, medical From such a definition, it is evident that the in- gynecology, office type surgery, and behavioral sci- sights and skills of preventive medicine would be of

43 —

44 /Prevention in Primary Care substantial importance to the functioning of the pri- there is little likelihood that the patient’s unarticu-

mary care physician. Preventive medicine, with its lated needs will be met. Since crisis care is the melding of social, economic, epidemiological and antithesis of comprehensive and continuing care (al-

statistical sciences, is a discipline which can enable though the management of crisis falls within the the new physician to affect the health of his patients purview of comprehensive care), the physician must by identifying incipient disease, flagging high risk have an attitude which conveys the importance of situations, mobilizing community resources, and by prevention to the patient (Blanchard, 1970).

working with other professionals to reduce hazards It is universally appreciated, I believe, that a few and remove barriers to good health. The responsi- patients, mostly women and children, present them- bility for the harmonious integration of these some- selves fairly regularly for “check-ups” which are what diverse elements with the curative and often directed more toward the detection of early rehabilitative aspects of medical care requires a disease than to identification of factors which con-

“global view” on the physician’s part. It also re- stitute risks to future health. With frustrating fre-

quires a willingness to work closely with other physi- quency, no active disease process is detected. cians, for no single physician can possibly possess Moreover, identified health hazards, such as obesity,

all the knowledge and skills needed to solve the many or abuse of alcohol or tobacco, are often not suf- complex health problems in his practice. ficiently disturbing to the patient to motivate a What, then, are the competencies required of the change in his habits or lifestyle.

primary care physician if he is to accomplish his In addition to the difficult and delicate task of task? Before addressing this question I must ac- arousing the patient’s concern about asymptomatic knowledge my own bias and identify the limits of my health problems without producing hypochondriasis,

comments. First, the scope of this paper does not the physician is aware that the effectiveness of many permit a detailed consideration of all of the com- popular approaches and techniques to prevent di- petencies required, but rather calls for emphasis on sease or disability are unproven. The question, “Does those competencies with preventive medicine con- preventive medicine really work?” deserves study tent. And, secondly, my only formal teaching ex- and careful testing under a variety of controlled sit- perience has been with a training program for uations. Results would be of great value to the physi- family physicians and, therefore, my positions and cian when planning effective allocation of his time statements must be seen in that light. and resources. For the prototype of effective primary prevention PREVENTIVE MEDICINE COMPETENCIES — active immunization against infectious disease

there is little question of its effectiveness. The pri- I will discuss the required preventive medicine mary physician must be conversant with the latest competencies under four headings: primary preven- recommendations in this area by the recognized tion; secondary prevention, to include early disease national and public health advisory bodies (World detection; patient education; and community medi- Health Organization, 1960; 1961; 1971). He also cine. needs a system of practice which is designed to assure periodic updating of each patient’s immuniza- Primary Prevention tion status. A description of one system will be found The protection and preservation of his patient's later in this paper. However, no system can substitute health may be the most important tasks of the pri- for the physician’s positive attitude toward preven- mary physician. Yet, in terms of time and effort de- tion, which may well be something he brings with voted to their accomplishment, they often receive him when entering the primary care field rather than scant attention during the average patient/physician something he acquires through training. A small

contact (Peterson et al., 1956; Baker and Parrish, study of incoming Family Medicine residents in

1965). Why is this so? A partial answer undoubtedly The University of Rochester Family Medicine Pro- lies in the perceived expectations of the patient, who gram showed that they had very positive attitudes usually presents himself to be restored to health, or toward preventive aspects of medical care. (See

to have his discomfort reduced if cure is not possible. Appendix I, this chapter.) Furthermore, review of

If the physician sees his responsibility as limited to the office medical records from several graduates of responding to the immediate, often self-limited crisis, the same program indicates that primary prevention Education in Family Practice/AS

is still regarded as an important part of office prac- screened occurring with sufficient frequency within tice two or three years after completion of formal the population at risk? Is it associated with signifi- education. cant morbidity? Will early detection benefit the pa- Competency in primary prevention, then, encom- tient? Do the screening tests available possess the passes the requisite knowledge, skills, and attitudes required degree of sensitivity, specificity, and repro- which will enable the primary physician to prevent ducability? And does the patient understand what the disease where possible, either through immunization testing procedures may mean to him in terms of cost against infectious disease, or through patient educa- and possible benefits? tion for patients exposed to identified health hazards. To make rational decisions in this area, the physi-

cian needs much more and better data than is cur- Secondary Prevention rently available, and he needs a good grounding in the epidemiological principles involved—two When the doctor discovers the presence of disease areas where departments of preventive medicine in his patient, his preventive medicine competency could make major contributions. must extend to limiting the impact of the disease on the patient, his family, and his community. Perhaps Patient Education the single most important aspect of secondary pre- One of the most popular beliefs held by laymen vention is the timely employment of rehabilitation and physicians alike is the one which asserts that measures. Like immunization in primary prevention, health education can be an effective method of im- there is little doubt that early steps to preserve and proving the health of the individual or the com- restore the patient’s abilities to function often dra- munity. The adherents seldom define what they matically decrease the potential social and economic mean by patient education. For our purposes, patient cost of the illness. Again, the critical element is the education means a deliberate effort on the part of doctor’s attitude toward the patient and his illness. To the physician to modify a patient's behavior by in- cite a common example, the patient recovering from forming him about health hazards and by recom- a recent myocardial infarction may function a great mending change. While this is a daily exercise for deal better when he returns to work if he knows his nearly everyone practicing clinical medicine when family and employer are aware of the “game plan” caring for individual patients with identified prob- for his resumption of normal activities. The key per- lems, the concept of education for cohorts of patients, son to minimize reentry shocks is the personal physi- or the practice as a whole, is seldom practiced. The cian. It is incumbent upon the teachers of primary primary physician must either learn to use techniques care to stress that curative skills also are not enough for educating groups of patients with identified risks, to do the comprehensive job required of the primary or employ someone else to do the job, if he hopes to physician. While it is not necessary that the physician change the health habits of considerable numbers of carry out the rehabilitative program personally, he is his patients. Education of inappropriate utilizers of responsible for seeing that it is done, and this implies medical care has important implications for practice a basic knowledge of rehabilitation as one of his management. Education of the whole practice may competencies. influence important health decisions for the com- Another aspect of secondary prevention involves munity for example, fluoridation of water, identifi- the notion that, in many instances, detection of dis- — cation of unmet health needs, etc. ease in its asymptomatic state will be of definite benefit to the patient. This appealing concept has Community Medicine been seriously challenged by several (Sackett, 1972;

Siegel, 1966; Boucot and Weiss, 1973; Ahluwalis One of the primary physician's tasks is to be able and Doll, 1968) who question the benefits derived to mobilize and orchestrate the health resources in from wholesale screening programs and periodic his patients’ community. To use a sport analogy, the health examinations. A rational approach to early primary physician, like a good quarterback, doesn't disease detection is clearly called for, and should be do everything on every play, but he does call the part of the primary physician’s competencies. To signals. More and more agencies are being formed to justify the cost of screening, he should be prepared to meet the health needs of certain types of patients. It answer such questions as: Is the disease to be is important for the physician to become familiar 46/Prevention in Primary Care with the kinds of assistance his patients can expect work for a teaching program; the second, to the from the health resources in his community so that he process or teaching method. can make appropriate referrals. This competency can be taught in graduate training programs which inter- The Structure face with the community at large as well as other medical disciplines. He must be equipped through The structure of any teaching program provides training and experience to guide patients with multi- the essential framework of boundaries and support faceted problems which often involve whole families, for the teaching process. The structure can be de- cross cultural and professional lines, and to help the scribed under the headings of setting, record system, patient surmount numerous obstacles to obtain the consumer group, and faculty, including relationships assistance needed. with other departments. In the following discussion, Besides mobilizing health resources, many primary 1 will use a Family Medicine Program as a proto- care physicians, by the very nature of their work, type because I am more familiar with programs in that field will participate in conceiving, organizing and operat- than other primary care disciplines. ing community based health agencies. Self-help or- Setting: Consideration of the environment in ganizations, service clubs and similar health groups which primary care is to be taught is of fundamental often need the expertise of physicians. The area and importance, for it establishes the proximity of teach- degree to which the primary care physician becomes ing resources, the general direction and emphasis within the its involved in community health problems will be de- program, and attractiveness to resi- termined by personal interest as well as expertise. dents. What are the necessary elements which will facilitate the Some will concentrate their energies in the area of learning of preventive medicine in a family direct care, and merely use well the resources avail- medicine residency? Perhaps the most essential is association of the residency able. More plan to help their communities identify element with a supportive individuals their health problems and plan for rational change. group of and institutions which have goals comparable to those of the resi- For this latter group, training programs should be dency in flexible enough to allow parallel development of skill program. The environment should be one in both clinical and community medicine. which teaching is at least as important as service or In summary, the preventive medicine competen- research. There must be a community of teachers and cies should enable the primary physician to identify students to generate enthusiastic pursuit of new high risk patients individually and by groups; to de- knowledge and better applications of old knowledge. liver comprehensive primary preventive care through Without such a community, a residency will be immunization, developmental guidance and availabil- limited to vocational training, and although it may ity as a knowledgeable source of health information; produce adequately trained physicians, it will have to limit the impact of disease through use of selected difficulty attracting the most innovative and challeng- screening procedures, early diagnosis, prompt care ing teachers and students. available com- and early rehabilitation; and to utilize The frequently raised question is where should a munity resources. primary care residency be located, in a university or Having stated the preventive medicine objectives community hospital? Either setting is compatible physicians, it remains for us to examine for primary with excellent performance providing the essential the resources needed to attain the objectives and to ambience and resources are present. Ideally, the describe how those resources can be combined and setting should combine both the realistic, pragmatic integrated into an effective teaching/learning expe- teaching ground found in good community hospitals, rience. with the community of learners and educational re- TEACHING RESOURCES sources associated with university settings. For purposes of illustration, a description of the setting for the University of Rochester Family Medi- It will be convenient to divide into two parts our consideration of the resources needed for the teaching cine Program may be useful. The program is a joint of preventive medicine competencies to physicians effort by the University’s School of Medicine and planning to deliver primary care. The first part will Dentistry and Highland Hospital, a major teaching be devoted to a description of the structure or frame- affiliate. A decision to locate the program at High- Education in Family Practice/ 47 land, a community-based hospital about two miles Practice Residencies specifically states that the from the University Medical Center, was based on model practice unit should simulate, as closely as the university’s recognition that the family physician possible, the conditions of private practice. The clear would be caring for patients in the community and intent is to avoid the crisis-centered operations of using community, rather than university-type, medi- the hospital emergency room, or the disease-oriented cal care facilities upon graduation. There were also approach to the patient so common in hospital based practical considerations of space and financial under- specialty clinics. The selection of a suitable site for

writing, which Highland Hospital was able to pro- the model practice unit is of crucial importance. Does vide. This important decision was made in 1966 by the site permit the unit to be part of the essential an Advisory Committee composed of chairmen of “environment of learning” described earlier? Is the selected major clinical departments at the University site easily accessible to patients, students, and fac- and their counterparts at Highland Hospital, together ulty? If the program depends heavily on inpatient

with administrative representatives. From the begin- services for teaching, is the site convenient for the

ning, the University recognized its fundamental re- residents? Is the site of the unit one which is ac-

sponsibility to make its analytical, planning, and edu- ceptable to the patients it hopes to serve, or is it cational skills available to the new program. At the burdened with old baggage—bus station waiting same time, the committee did not dictate either the areas or long subterranean passages through the form or the content of the new program. It tried to bowels of a hospital? And, finally, has space been avoid the hazard of putting new wine in old wine provided for teaching and research as well as patient skins. care? Several of these questions will be considered Rather than develop a new, free-standing and in some detail because of their obvious implications separate department of family medicine, the Univer- for community and preventive medicine departments.

sity decided to create a division of family medicine Careful consideration and selection of the patient

which would be the joint responsibility of four uni- population is crucial. If one intends to attract some versity departments—medicine, pediatrics, pre- middle and upper class patients, the model practice ventive medicine, and psychiatry. By this unit should be located with their expectations and

arrangement, the disadvantages of slightly diminished concerns in mind. By the same token, if one recog- autonomy and prestige of division status was offset nizes the importance of including lower socio- by direct commitment of each of the parent depart- economic groups in the training program, the loca- ments to the success of the program. It was under- tion should be near public transportation. An stood from the beginning that many of the residents’ early decision at Rochester was to develop a teaching clinical skills would be acquired through inpatient practice population with demographic characteristics rotations and, therefore, the traditional clinical de- mirroring, as far as possible, Rochester as a whole. partments would have major teaching responsibili- In this way, we planned to provide residents with

ties. Family medicine was also viewed by the four the experience of caring for families from the various departments as a field which contained many areas cultural, ethnic, social, and economic backgrounds of mutual interest and the possibility of new forms represented in our city. We wished to avoid the of interdepartmental cooperation. At the undergrad- overwhelming experience of assuming comprehensive uate level, for example, joint teaching exercises in- care for large numbers of multi-problem, disadvan-

volving medicine, preventive medicine, psychiatry, taged families. Success in achieving this goal is

and family medicine have allowed students to ex- reflected in Table 1. Hammond and Kern (1959)

amine the impact of chronic disease upon the patient, pointed out several years ago that it is difficult to his family, and the community. Although the Roches- maintain enthusiasm for preventive medicine among

ter program is primarily designed as a residency students who are caring only for patients whose needs training program, undergraduate students from and demands are sharply focused on the present. Rochester and elsewhere have successfully partici- While our location, adjacent to a community hospital pated in research and patient care aspects of the in a multi-class neighborhood, did not provide easy program. access to the inner city population, many came any- One of the unique features of residency training way, thereby demonstrating strong motivation to in family medicine is the model practice unit. The obtain “middle class” medical care. Had access to Accreditation Commission Guidelines for Family the inner city been easy, we could have been over- 48 / Prevention in Primary Care

TABLE 1. Socio-Economic Class Distributions of Monroe ambulatory patients much easier. The adjacent hos- County and Family Practice Populations pital also provides convenient access to many con- Monroe County Family Medicine sultative services and educational resources. The 1 Population Practice Population proximity of the hospital and the intimate relation- by Socio-Economic by Socio-Economic ship between program and hospital staff provides Class Class (8/73) the residents with opportunity to work with other S.E.S. Population % Population % professionals in solving problems of mutual concern. I 104,492 15.1 853 11.0 The physical structure of the model practice unit II 224,837 32.5 2,217 28.5 should facilitate the team approach to patient care. III 256,803 37.1 3,173 40.8 Some of the basic requirements are centrally located IV 70,675 10.2 1,141 14.7 V 34,905 5.1 371 4.8 medical records, easily accessible to all teams; sufficient number of conference rooms which can 691,512 100.0 7,775 99.8 double as teaching and demonstration areas; office 1 Based on 1970 Census, U.S. Department of Commerce, space for on-site associates like physician assistants Social and Economic Statistics Administration, and Five- or social workers; a laboratory for routine office part Composite S.E.S. Jndex by Wagenfeld & Willie, “Calcu- tests and easily accessible diagnostic radiologic fa- lation of Socio-Economic Areas of Rochester and Monroe County, New York” Rochester, 1966. cilities. Even the patient waiting area deserves care-

ful planning. it (S.E.S. I is the highest and S.E.S. V is the lowest.) Not only should convey a warm, re-

laxed and comfortable impression, but it should also have a play area for children and an educational area whelmed by the demands for crisis care. Certainly for adults. more time, money, and personnel would have been So far, we have considered the environment and diverted to out-reach, community type services. location in which primary care may be taught effec-

Preventive medicine can bring its epidemiological tively. The next part of the structure is the group of and statistical skills into the family practice unit to people assembled to carry out the tasks of the pro- demonstrate the usefulness of its discipline for the gram. Just as the tasks of education, patient care practicing physician. The model practice unit is a and research are interrelated and often overlap, so do research model as well as an example of one method the roles of individual staff members, particularly of health care delivery. One of the competencies ex- faculty. The point at which the various members of pected in the primary care physician is an ability to the staff have the greatest degree of interaction, and collect and analyze data about his practice. He must where most of the teaching within the model practice

actually be able to use the data to answer questions unit occurs, is in meeting patient needs. The needs

important to him if he is to carry research tools with may require only a straightforward and relatively him into practice. In the press of residency training, uncomplicated response on the part of one member with the many demands on the resident’s time, the of the health team, such as would be sufficient for an accessibility of data, whether in a morbidity index or acute, self-limited illness. Or the patient and his a patient’s record, often determines its usefulness. family may need special assistance from several staff And the same is true in practice. members—patients with combinations of social, psy- Many of these considerations determined the lo- chologic, and medical problems are obvious cation and form of the model practice unit. The examples. University of Rochester Unit occupies one floor in The staff includes faculty, residents, nurse prac- a professional building, adjacent to Highland Hos- titioners, nurses, health assistants, secretaries, ad- pital, a 300-bed community hospital. Separate park- ministrative assistants, and laboratory personnel. Al- ing areas, entrance and elevators serve the building. though residents are customarily thought of as being

Other private physicians occupy offices on adjacent taught by the staff, it is more rewarding to regard floors. The model practice unit is connected by a them as colleagues in a joint enterprise, for then corridor to the hospital. Since most of the residents’ they can function more comfortably and productively

inpatient service time is at Highland, travel time is within a team setting. Virtually without exception,

less than if the model practice unit were located the residents intend to practice their specialty in elsewhere. Having one’s office within a few steps of partnerships or groups rather than as solo practi- hospitalized patients makes the care of both bed and tioners. Moreover, they intend to work with other Education in Family Practice / 49 health care providers such as nurse practitioners, if he hopes to do more than just respond to the physician assistants, public health nurses, social complaints of those who come to him. workers, psychologists, pharmacists—in fact, every- Registry: Essential for the comparison of popu’a- one who can contribute to improving the patient’s lot. tions is standardization for age and sex, since the The concept that the patient would benefit if more prevalence and patterns of disease are strongly de- of his day-to-day health care needs were provided pendent upon those variables. Knowledge about the by non-M.D.’s is realtively new (Allied Health Per- age and sex distribution within a practice also personnel, 1969). We now see many programs develop- mits certain operational decisions to be made on a ing to train a variety of non-M.D. health care pro- rational basis. For example, analysis of the age/sex viders (Smith, 1970; Bates, 1972). Most of these data might support an impression that someone with programs, as well as primary care training programs appropriate skills for a specific age group could be for physicians, see their graduates working in a com- adequately employed. Such an impression would be plimentary way. From a teaching point of view, it enhanced further if year-to-year comparison, dem- will be important and perhaps essential that each onstrated consistent trends within the practice. discipline learn to work closely with the other to The establishment of an Age/Sex Registry is a bring coherence to the medical care scene. For pre- simple matter at the beginning of a practice, and its ventive medicine, these developments present chal- maintenance requires a minimum of time, skill and lenging opportunities to help clarify roles by measur- space. In an established practice, construction of a ing the impact of new health workers on the com- registry is a more formidable task. munity, by evaluating and comparing different ap- The registry can consist of plain 2% by 31/2 inch proaches to primary health care delivery. cards on which the individual patient’s name, birth

Strange as it may sound at first, we have orga- date, and census tract or other identifying informa- nized our teams around the secretary, as she repre- tion is entered. Color coded file cards' specially de- sents a relatively fixed, accessible and familiar person signed for a registry have been developed by The for the patient. The secretary schedules the appoint- Royal College of General Practitioners, and contain ments and does the other customary tasks expected conveniently arranged space for recording additional of a doctor’s secretary. In the model practice unit, data if desired, and can be “notched” for needle however, she has several part-time doctors (resi- sorting (Eimerl, 1969). By convention, red cards dents) and a nurse practitioner on her team in addi- are used for females, blue cards for males. Once en- tion to a faculty member, who functions as the team’s tries are made, the cards are filed by year of birth leader. When a patient cannot be given an appro- and sex. Thus, all males (blue cards) born in 1972 priate appointment with “his doctor,” the secretary will be grouped together adjacent to the group of schedules a visit with another member of her team. females (red cards) born in the same year. Within This process both simulates coverage arrangements each color grouping, the cards are arranged alpha- common in private practice and limits the sharing of betically. Thus, at a glance, with simple counting, care to a small group. The team meets as a group one can obtain a profile of the practice.

every week to thrash out procedural problems, plan In order to make the registry reflect the current conferences, and clarify roles and responsibilities. patient care population as clearly as possib’e, peri-

Record System: If one is to compare the results odic updating of the registry is essential. To facilitate of health teams, whether they are within the same removal of patients’ cards who are probably no

unit or in different units, one must have sets of com- longer using the practice, a colored tab is placed on a parable data. If one plans to make rational choices conspicuous edge of the folder holding the patient’s

involving the operation of a practice, one needs medical record the first time the patient contacts the informative data about the operation on which to practice in the current calendar year. A different

base the decisions. If a physician expects to “learn colored tab is used for each subsequent year. If the

from his practice,” he must choose a method of medical records are filed on open shelves, it is an recording and retrieving important data about co- easy task to identify folders of patients who have not horts of patients so that he can review his manage- contacted the practice, and to then remove their ment of groups of patients with similar problems, or cards from the registry. The usefulness of the data ages, or geographic locations, or socio-economic derived from this method of identifying patients status. And he must be able to do these sorts of things within a practice needs to be tested, and constitutes 50/Prevention in Primary Care one of the several areas where the expertise of nostic index is a systematic grouping of patients epidemiologists and biostatisticians can be im- under an arbitrarily limited number of rubrics which mensely helpful. were selected to reflect types of disease and prob- Another profile of a practice population can be lems commonly encountered in primary care settings. obtained by grouping medical record folders on open Because problems, symptoms, and other ill-defined shelves according to geographic areas served by the states are included among the rubrics, the index is, practice. If the areas can be characterized in social in fact, a morbidity index. Readers interested in a and economic terms, additional profiles may be ob- detailed description of the diagnostic index (or “E” tained. For example, certain social and economic Book) should consult papers by Eimerl (1969), characteristics are known about the census tracts in Froom ( 1974), and Metcalfe ( 1972). I wish to focus our area, and the relatively dense population makes on some of the ways such a collection of pertinent use of census tract filing practical. In less dense morbidity data can be used to teach preventive medi- areas, other geographical divisions such as school cine. districts, postal zones, or townships, can be used. When each resident either keeps his own index or The selection of a particular method of filing should has a computer printout available to him, he can depend upon what use one intends to make of the quickly review the recognized morbidity within his filing system and the costs involved. The possibili- practice. With the minor addition of two modifiers ties for useful epidemiological studies are numerous. to the three digit code for each problem entered in One could easily study the patterns of disease as they the index, he can distinguish incidence and preva- appear within the practice, the difference in utiliza- lence. As his practice experience grows, he can tion rates between different geographical areas, the scrutinize cohorts of patients with accidents, poison- prevalence of disease among various social and eco- ings, acute rheumatic fever, suicide, invasive carci- nomic groups, the association of suspected environ- noma of the cervix, and iron deficiency anemia, to mental hazards with the appearance of disease, name just a few. Review of his cases should stimulate and so forth. The close correlation of census tract several questions: Could any of these problems be divisions with the age of the housing in our area prevented? How does my practice compare with enabled us to easily identify all households within those of my peers? Am I overlooking important our practice at high risk for lead poisoning. Once problems, or are they not present in my practice? I identified, the parents of children at high risk were wonder why I am seeing so many XYZ diseases? Is contacted by letter and urged to come in for testing. it because I look for it more than others? Why do Of the 75 thus identified, 40 responded to our ap- most of my patients with problem ABC come from peal, and the records of the others were flagged. one census tract?

At first thought, geographic filing may seem un- Problem-Oriented Medical Record: Since the ac- duly cumbersome. It does require a master locator curacy of the entries in the diagnostic index is no file where all patients are cross referenced with the better than the diagnostic acumen and coding pre- geographic areas. However, our experience has cision of the physician making those entries, anyone shown that reference to the master file is needed only analyzing the data would want to examine the evi- for those unfamiliar with the patient. The five team dence which supported the diagnosis. The only docu- secretaries in our model practice unit have so ment containing such evidence is the patient’s medi- thoroughly associated individual families with census cal record. We insist that a logically constructed and tract numbers that they can usually go directly to the carefully maintained medical record is essential for appropriate section of the files and retrieve the efficient review. We also believe that the self- record. (Each team is responsible for about 500 discipline required contributes to better patient care families.) When one is familiar with the location of by reducing unnecessary tests, medication errors, and individual census tracts, one can obtain an overview overlooked problems. The format we have adapted is of where the patients live by viewing the open shelves based on Weed’s Problem-Oriented Medical Record with their clusters of distinctively colored folders. (1969). Near the front of every patient’s record is a Diagnostic Index: Another important element in distinctively colored page containing a list of those our data collection system with important applica- health problems judged to be of continuing concern tions in the teaching and practice of preventive medi- by the doctor. Beside each problem appears a diag- cine is the diagnostic index. Simply stated, the diagnostic code number and the date when the diagnosis 1

Education in Family Practice / 5 was made. The same code number appears beside all cians in our area joined our data collection system. the doctor’s progress notes relative to that problem. In time it should be possible to display for each

The problem list serves as a master key to unlock resident and practicing physician a profile of the the evidence in the medical record for each problem problems he has recognized and coded. Appropriate on the list. Moreover, if it is reviewed at each visit, adjustments for differing age, sex, and socio- as it should be, previously identified “high risks,” economic factors within each practice should permit which are considered to be problems just as worthy worthwhile comparisons. Such comparisons should of inclusion on the list as the presence of serious help to identify educational deficiencies, problems in disease, are brought to his attention. practice management, or trends in practice. As a supplement to the master problem list and All of these elements of data collection and analy- the titled and code-numbered progress notes, we have sis are integral and important parts of what I re- found flow charts useful for displaying data in a ferred to earlier as the structure of family medicine. compact and rapidly reviewable form. Two examples With appropriate modifications, I believe they are are particularly pertinent to primary preventive useful in any primary care setting which intends to medicine: An immunization grid, which contains the promote both comprehensive and continuing care. patient’s immunization history, current status and In our teaching, we have placed considerable em- recommended procedure; and a health maintenance phasis on systems and organization because we be- grid, suited to the patient’s age and sex, which shows lieve modern health care demands it. We also believe the examiner when certain screening tests and pro- that the thoughtful discipline required to perfect and cedures were last done. Which member of the health maintain the structure enhances the probability that

team is responsible for review and maintenance of the individual patient will receive maximum benefit

these patient care areas is a decision left to the teams. from his encounter with his health care provider. In addition to acquiring skills and knowledge for The Consumer Group: With so much emphasis on the accurate recording of demographic and diagnostic organization and systems, we are concerned that the data, the primary care physician needs a working structure may become so rigid or complex that legiti- knowledge of elementary statistical principles and mate patient needs may be lost in the interstices.

methods if he is to analyze this data and draw valid One major approach to monitor this potential prob- conclusions. He should be familiar with the princi- lem has been the development of a consumer ad- ples of frequency distribution, population sampling, visory group. This has been accomplished primarily tests of significance, and the concepts of association through the offices of a social worker on the faculty. and causality. For specific application, in practical A letter of invitation was sent to the entire practice.

circumstances, he will probably need the assistance of Sixty-eight patients responded (a little less than 1 expert statisticians and preventive medicine special- percent of those over age 24) to form a consumer

ists. The statistician or preventive medicine specialist advisory group. They in turn elected a steering com- will, in turn, find he can be more helpful if he has mittee for the purpose of securing developmental

an understanding of clinical practice as it exists in a funding. Our immediate objectives are to familiarize primary care setting. the consumers with our program’s objectives, particu- One major structural aspect of practice with which larly in areas other than direct patient care. The pub-

the combined efforts of the preventive medicine and lication of a newsletter is one step in that direction.

family medicine/primary care disciplines can come Another immediate objective is to let the resi-

to grips is peer review. This is particularly true with dents interact with patients in a setting where ques- respect to development of a peer review process for tions from the patients are as appropriate and desir- ambulatory care. The participation of family medi- able as from the doctor. Long-range objectives are cine residents in the development and operations of to involve consumer representatives in many areas of such a process must be considered a major structural policy, planning, operation, and evaluation of the component of the residency. If my five years ex- Family Medicine Group. Possible projects in these perience of teaching Family Medicine residents is areas with implications for preventive medicine are

any indication, the typical resident is eager to com- sponsorship of health education classes, conducting pare the quality of care his patients receive with community surveys, identifying unmet health care

predetermined norms or with other groups (Metcalfe needs. It is our hope and expectation that the value of and Mancini, 1972). Recently, 28 practicing physi- direct consumer participation can be demonstrated to 52/Prevention in Primary Care our residents and that they will incorporate the lesson The necessity for validity extends beyond the set- learned into their own future practices. ting in which the primary care skills are learned, to

Faculty: “Who should teach the primary care the teachers who expound them. While it is essential, physician?” is a question that has been raised in I believe, to have appropriate role models for the many quarters. If we grant, as I believe we must, that resident, it is equally important for teacher and resi- the primary physician must be superbly educated if dent to understand that the ultimate objective of the he is to do a first class job in a broad and demanding program is to produce physicians who are different field, then the quality of this teacher should be at from their teachers in many important ways. In this least equal to those of any other disciplines. It is respect, particularly, primary care physicians should self-evident that our medical education system, with learn in programs where the teaching emphasis is its emphasis on subspecialty training, has not pro- educational, rather than vocational, in nature. The duced an adequate number of primary care physi- distinction is not just semantic, for the future primary cians with the requisite combination of ability and physician (as defined at the beginning of this paper) motivation to teach what is known and to explore will be recognizably different from most of those what is unknown in primary care. The cause is ap- providing primary type care today. parent: young physicians in university affiliated resi- For example, the internist planning to function as dencies seldom have significant contact with practic- a primary physician will need to have some basic ing physicians, to say nothing of full-time teachers of knowledge and skill in gynecology, in the recognition primary care. It will take time to develop a cadre of and management of emotional illness and in the teachers for the primary care discipline and it is in- principles and techniques of rehabilitation. Since evitable that many of the early graduates of the cur- these areas are not usually taught by internists, they rent primary care programs will respond to that need must be learned from noninternists. The same thing for career teachers and thereby temporarily reduce can be said for primary pediatricians, and most of the impact of these new programs on the supply of all for the family physician, the most broadly trained primary care physicians. of all. Of necessity, therefore, close cooperation be-

Since there is a scarcity of qualified teachers, the tween the several departments is essential. new programs must look to the well-established tra- One mechanism for promoting a cooperative spirit ditional disciplines for teaching in specific areas. is the joint multiple appointment system. In this

Using the model described by Hilliard Jason ( 1970), system, each faculty member among the primary the traditional disciplines can provide component physician group receives an appointment in sister knowledge and skills which when combined with the departments which have made their teaching respon- developing knowledge and skills peculiar to primary sibilities for primary physician residency programs. care can produce a new composite physician. With This administrative step legitimizes the working re- reference to preventive medicine, the needs are evi- lationships, fosters mutual support, and facilitates dent. The primary physician’s task will be preven- the exchange of ideas. tive as much as curative; the minimizing of the With regard to faculty, two —additional questions impact of disease will not suffice. To accomplish this must be answered. The first is “What should the task he needs to be able to define realistic obtainable resident/faculty ratio— be for these new programs?” objectives in health care, to use epidemiological skills And the second is “Can the private practitioner to determine both the dimensions of the tasks before participate?” The answer to the first depends upon him and the effects of intervention. He also needs to the extent teachers in traditional disciplines are able be familiar with community resources and how best to help carry portions of the teaching load. Millis to mobilize them for his patient’s benefit. These skills ( 1971 ) recommends a national average ratio of medi- can provide one component. When integrated with cal students to faculty of 2Vi to 1. As yet, there is components from internal medicine, pediatrics, be- insufficient experience with graduate programs for havioral science, and other selected disciplines, these primary physicians to know what an average ratio skills can produce an effective primary care physi- might be, but there is accumulating evidence that cian. It is generally accepted that this integration can education in ambulatory settings is more costly than most appropriately and effectively take place in a in an inpatient setting. The ratio of students to faculty setting simulating front line practice with its “real in family medicine programs varies from 2 to 1, to life” validity. 10 to 1. A 5 to 1 ratio appears satisfactory provid- Education in Family Practice/ 53 ing inpatient teaching is shared with other depart- rotations, an example of a problem-oriented medical ments. The answer to the second question is a record, and other information regarding the program. qualified “yes.” The qualification has nothing to do Although the resident spends eleven of his first with the practicing physician’s fund of knowledge or twelve months on such inpatient services as medicine motivation but rather a misinterpretation of the (4 months), pediatrics (3 months), obstetrics (2 teacher’s tasks in graduate medical education. If the months), and surgery/emergency room (2 months), practitioner can comfortably use the Socratic or he returns to the model practice unit two half-days heuristic approach, he will be much more effective per week to care for his ambulatory patients. The with the current graduate physician than if he falls patients are assigned by families (or households) as back on many of his own role models who tended to the families request medical care until each first be authoritarian and dogmatic. year resident has approximately 50 families in his “practice.” The resident records each contact with The Process the family in that family’s medical record, and each

In the preceding sections of this paper, we have contact is reviewed by the resident's team leader, a considered various components of the setting in full-time faculty member. Comments on form, con- which Family Medicine Residents, as prototypes of tent, and patient management are returned to the primary care physicians, learn preventive medicine. resident, either orally or in writing. Periodically, the

We have also described the competencies required in entire record is audited. (Appendix II, this chapter). preventive medicine and the structure of a training Faculty have regularly scheduled times in the program. We shall now look at the process by which model practice unit when they are to function as the resident acquires the attitudes, skills, and knowl- preceptors of the residents. No patients are scheduled edge needed to perform effectively. for the faculty member during those hours. He is Selection: The selection process, which is a joint available to all the residents for consultation and re- effort involving residents and faculty, tries to select view in the unit at that time. One of the preceptor's applicants whose career goals are consonant with the objectives is to help the resident view the patient's goals of the program. Part of the process consists of immediate problem in the context of the patient’s interviews with three members of the Selection Com- psychological make-up, his roles in his family and mittee, who try to assess, among other qualities, the community. Often this approach uncovers areas applicant’s attitude toward primary care in general where the resident can initiate action to limit the and family medicine in particular. We have relied impact of the problem on others as well as the pa- heavily on the impressions gathered from the inter- tient. Both the preceptor and the auditor can assess views in making our final choices. An indication that how effectively the resident is using his time with the this selection process tends to bring to the program patient for health surveillance, and recommend ways residents with the desired attitudes can be seen in the to improve his performance. results of an attitude test given on the day the resi- During the resident’s second and third year, he dents begin training. The test instrument consists of increases both the time spent in the model practice questions designed to assess attitudes toward con- unit and his patient load as he decreases his in- cepts, positions, and situations commonly encoun- patient responsibilities. During these years, he can tered in family practice. Several questions involved choose electives which expose him to health care attitudes toward preventive medicine and rehabili- problems within the larger community. Some elect tation. There was close agreement among the resi- to work with school physicians and psychologists, dents—closer, in fact, than among the faculty! and some elect to plan better ways for getting health (Appendix I, this chapter). care to special groups of patients. Others work for

Training: The residency begins with a four-day short periods in different settings, and still others take orientation period designed to let the resident get a year’s leave of absence to obtain an advanced acquainted with faculty and staff, to meet and inter- degree in community medicine. (Appendix III, this act with members of his team, and to begin to learn chapter). The accommodation of diverse interests in about our systems. Each resident receives an up- one program is a tribute to the supportive elements dated “Family Medicine House Officers Manual” in the program’s environment. containing descriptions of his responsibilities, the During his third year, the resident receives his first roles of all personnel, the objectives of his inpatient intensive exposure to rehabilitation medicine. Each 54/Prevention in Primary Care

resident is required to complete a two-month rota- It is important for the resident to have sufficient tion on one of the University’s teaching rehabilitation time and stimulation to undertake studies which will services. Also during his third year he acquires addi- have “carry-over” value in his practice. And he tional counseling skills during a two-month rotation needs ready access to educational resources. in ambulatory psychiatry. The wealth of resources available to developing

It must be emphasized that the resident is released programs is probably the overriding reason to pre- two or three half-days per week from other services fer a university setting. Not only do universities have

to care for “his patients” during the entire three schools and departments representing allied fields, years. He thereby has the opportunity to observe and extensive libraries with ready access to instructional care for families over a significant period of time. materials, but many are located in areas with a We believe the knowledge and skill gained as he sufficiently dense population to support a variety of helps families cope with their problems will be very public and private health agencies. In a university

helpful in his practice. setting, the problem is not so much where to find

Conferences: Residents at all levels participate in the resources as it is to mobilize and coordinate them team conferences held weekly or biweekly. The pur- effectively.

pose of meeting as a team is to allow open discus- What are the educational resources needed in the

sion among all members regarding roles within the model practice unit, in the hospital, and in the com- team, operational problems, and research projects. munity?

Each team is in turn responsible for choosing The unit should have its own educational resource

and presenting the results of a study to the entire center consisting of a library, reference files, and program two or three times a year at a weekly self-instructional materials. The library should con- Family Medicine Conference. Most of these studies tain carefully selected reference works, periodicals require gathering and analyzing data from the prac- pertinent to primary care, and adequate working

tice. The importance of a system which permits space so that the reference works remain in the li- efficient retrieval of data is—reinforced. A sample brary. In planning the library, one must remember study dealt with the question “Screening for Cervi- that it is part of a functioning model practice unit. cal Cancer—How Well Are We Doing?” The team Only books useful to the physicians in training should

presenting this subject first reviewed the literature be included, if space is an important consideration

and arbitrarily selected an acceptable standard of as it usually is. Cataloging and arranging the vol- performance. Certain groups were selected for study, umes according to subject will increase the library’s the patients in our practice identified (Age/Sex usefulness. Where possible, the integration of the Registry), and their records reviewed. The percent- library with a large hospital or university library can age of patients known to have received a Pap Test facilitate the exchange of educational materials. Self- within the specified time interval was determined instructional materials would include audio and vis- and compared to the previously agreed upon stan- ual tapes, selected programed learning kits, slides dard. Out of this study, which showed that only 63 and projectors. The reference files would contain percent of our 35 to 40 year old female patients had articles from current literature, position papers, pro- been screened during the preceding two years, came tocols, or whatever was considered to be of immedi- recommendations for a simple method of reminding ate practical value for the day-to-day use of the patients when their next test was due. A follow-up residents. We have arranged these files according

study is planned. to The Royal College of General Practitioners Modi- Another conference was devoted to consideration fication of The International Classification of Dis- of what constituted comprehensive prenatal care; an- ease. A resource paper entitled “Community other critically examined which screening tests Resources for Prenatal Patients” would be located should be performed on an asymptomatic male in “Section XI—Pregnancy, Childbirth and Pue- between 20 and 40, and how often. Both of these perium.” Divisons within each section are marked by topics required a literature search in addition to the same code numbers as the diagnostic index. analyzing data from the practice. And both topics Thus, the latest recommendations from the American raised a myriad of questions about cost/benefit re- Academy of Pediatrics or the U.S. Public Health lationships for the patient, many of which could not Service on immunizations would be found under be answered because of insufficient data. Code No. 905, “Prophylactic Inoculation or Vac- Education in Family Practice/ 55 cination” in “Section XVIII—Supplementary Classi- teaching support for July, 1974. The health center fication.” Since our residents are familiar with the pays a portion of the residents’ salaries and educa- code because they use it daily to classify what they tional costs. The center, which from the beginning have seen or the reason for the patient’s visit, the had adopted the family medicine model, including thought associations have already been established. data systems, regards the educational costs as in- Within the unit or conveniently adjacent should be vestments to attract well trained community-oriented suitably equipped space for conferences and small physicians. For a program training primary care group discussions. Probably some of the most ef- physicians, this affiliation strengthens the community fective patient counseling and education takes place medicine aspect of the teaching, it broadens and when patients participate in small group work rather deepens our contacts with the community, it allows than receive a lecture, or view a video-tape. There- close observation of graduates in “front line situa- fore, conference areas should be convenient for pa- tions,” and it distributes some of the costs to those tients as well as for the staff. most likely to be benefited.

An important potential community resource is the neighborhood health center with its orientation to- CONCLUSION ward providing health care services for all persons living within a certain area. Those centers which Implicit in this paper is my position that preven- operate under consumer bodies, use the health care tive medicine and the primary care disciplines can team approach, and collect data on morbidity and and should be closely linked. Each has a great deal utilization, can provide the community-oriented pri- to offer the other. Preventive medicine, which tends mary care physician with valuable learning experi- to concern itself with health problems arising from ence. the environment and communal living, needs better Our experience with community-based health cen- access to data about the health problems of indi- ters has been increasing. In 1970, two graduates of viduals and families. Primary care physicians, on the Rochester Program joined Westside Health Serv- the other hand, need a more comprehensive under- ices, a federally funded agency which plans separate standing of the communities in which their patients incorporation this year. As a result of the experi- live. If preventive medicine also provides the pri- ence with the two family physicians, the health cen- mary care physician with portable, useful tools in ter’s board acted on recommendations of its medical epidemiology, biostatistics, and operations research, director to provide space, support, and funding for cooperative and joint efforts in many important areas one first year resident to establish his base practice of health care research should be one significant at the center in 1973. This arrangement has proven result. Equally important should be the professional so satisfactory that the center has arranged for two satisfactions accruing to the practicing physician and first-year, six second-year residents, and additional the health benefits provided to the patient. ) )) ) )

APPENDIX I

Response of Residents 1 and Faculty 2 to Selected Statements in Attitudinal Survey

6. “In medical practice today, there are sufficient specialists so that a family physician need not assume long term responsibility for patients with chronic

Agree Completely For The Completely Disagree Disagree Undecided Most Part Agree

R(ll) F(3) R(6) F( 1 R F R F R F

9. “In family practice, most patients are not willing to pay for disease prevention or health maintenance.”

Strongly Strongly Disagree Disagree Undecided Agree Agree

R(2) F(2) R( 10) F( 1 R(4) F ( 1 R(l) F R F

11. “How important do you think it is for the family doctor to be able to utilize the nonmedical specialists (social worker, psychologist) in his community?”

Pretty Pretty Unimportant Unimportant Undecided Important Important

R F R F R F R( 1 ) F(2) R(16) F(2)

27. “Health maintenance is neither as interesting nor as profitable as curative medicine for the physician.”

Definitely Definitely Not No Undecided Yes Yes

R(6) F R(6) F( 3 R(4) F R F ( 1 R ( 1 ) F

34. “Except for certain contagious diseases, specific knowledge pertaining to

disease prevention is so fragmentary that a physician should limit his efforts to curative medicine.”

Strongly Strongly Disagree Disagree Undecided Agree Agree

R(4) F ( 1 R(13) F(2) R F R F(l R F

1 Residents entering Family Medicine Program. 2 Full-time Family Medicine Faculty. APPENDIX II

Check List for Audit of Family Medicine Records

Name of Patient: Name of Doctor:

Name of Auditor:

Date:

Yes No Yes No Yes No

1. Is the demographic data complete?

2. Is there a properly constructed complete Problem List?

3. Is the Data Base complete?

4. Are the Progress Notes Problem- Oriented?

5. Does the record clearly reveal the cause, 10. status, and future plans for each problem?

6. Was Health Maintenance reviewed and

is it current?

7. Were the investigations of problems logical and appropriate?

8. Was therapy logical and appropriate?

9. Were “No-Shows” followed up?

Was every symptom noted by the nurse picked up by the doctor?

Comments: ..

APPENDIX III

Timetable for Introduction of Preventive and Community Medicine Concepts and Practices

FIRST YEAR

Orientation Period 1. Determining residents’ background, knowledge and attitudes

2 . Outlining available community resources

3. Overview of Preventive Medicine in program

Block Time — 1. Audit of patient care records (see Appendix II) Family Practice Unit 2. Thrice weekly patient oriented conferences where primary and secondary prevention can be discussed

3. Twice weekly topic oriented conferences where screen-

ing, outreach, journal reviews, etc., can be reviewed

Block Time — 1 Rounding and bedside teaching by Family Medicine In-Patient Services faculty provides opportunity to ask: “Could this illness

have been prevented? What is being done to avoid complications? Plans for rehabilitation? Impact of

illness on family?” etc.

Block Time — 1 Accident and poisoning prevention Emergency Department 2. Drug control programs

3. Problems with medical care delivery system

SECOND YEAR

Block Time — 1 Conferences—same format as First Year Family Practice Unit 2. Peer review using patient records in model practice unit 3. Visit community agencies

Block Time — 1. Review literature pertaining to diseases seen in his In-Patient Services patients

2 . Present Preventive Medicine aspects of care at case conferences, grand rounds, etc.

THIRD YEAR

Block Time — 1. Intensive exposure to principles and practices of re- Rehabilitation habilitation medicine Education in Family Practice/59

Block Time — 1. Participate in design and implementation of studies Family Practice Unit on Family Practice patient population 2. Prepare up-date from literature on specific Preventive Medicine topics 3. Participate in seminars on health care delivery, practice management, etc. 4. Design and carry out selected screening programs 5. Participate in consumer education programs 6. Participate in patient education programs and in-

service education of staff 7. Spend time with other models of health care delivery (Indian Health Service, British National Health Serv-

ice, etc.)

8. Study effectiveness of health care delivery to selected populations (immigrants, prisoners, welfare recipients, etc.) 60/Prevention in Primary Care

Metcalfe, DHH and JC Mancini 1972. Critical event

outcome studies used as a teaching tool. J Med Educ 47: REFERENCES 869-872.

Metcalfe, DHH 1972. Knowing what goes on or cohort

review in primary care. Del Med J Sept, p 252-256. Ahluwalis, HS and R Doll 1968. Mortality from cancer

of the cervix uteri in British Columbia and other parts of Millis, JS 1971. A rational public policy for medical edu-

Canada. Brit J Prev Soc Med 22:161-164. cation and its financing. The National Fund for Medical Education, New York. Allied Health Personnel 1969. Ad hoc committee on allied health personnel. Washington, D.C., National Acad- Peterson, OL, LP Andrews, RS Sprain and BG Greenbert emy of Sciences. 1956. Analytical study of North Carolina general prac-

tice, 1953-54. J Med Educ 31:165. Baker, AS and HH Parrish 1967. What do rural GP’s in Missouri really do in their offices? Mo Med 64:213. Report of the Ad Hoc Committee on Education for Family Practice of the Council on Medical Education, AMA Bates, B 1972. Changing roles of physicians and nurses. 1966. In Meeting the challenge of family practice. Wash State J of Nursing, p 3-9. Report of the Citizens’ Commission on Graduate Medical Blanchard, H 1970. The attitude creates the situation. Education, AMA 1966. Chicago. Arch Environ Health 21:113-116. Sackett, DL 1972. The family physician and the periodic Boucot, KR and W Weiss 1973. Is curable lung cancer health examination. Can Family Physician 18:61. detected by semiannual screening? JAMA 224:1361-65. Siegel, GS 1966. An American dilemma—the periodic DHEW 1973. Grants for training in Family Medicine. health examination. Arch Environ Health 13:292-295. Health Resources Admin. Washington, D.C., Government

Printing Office. Smith, RA 1970. Medex. JAMA 211:1843-1845.

and Willie 1966. Calculation of socio-eco- Eimerl, T 1969. A handbook of research in general prac- Wagenfeld

tice, The Royal College of General Practitioners. England, nomic areas of Rochester and Monroe County, New York E and S Livingston, Ltd. In Five-part Composite S.E.S. Index. Rochester.

1969. Medical records, medical education and Froom, J 1974. An integrated system for the recording Weed, L Press of Western Re- and retrieval of medical data in a primary care setting, patient care. Cleveland, The Case serve University. Part 3. J of Fam Pract 1:45-48. Health Organization: Expert Committee on Rabies, Hammond, KR and F Kern, Jr. 1959. Teaching compre- World Series 201, hensive medical care. Cambridge, Mass., Harvard Uni- Fourth Report, WHO Technical Reports, No versity Press. 1960 Geneva.

World Health Organization, The role of immunization in Health is a community affair 1966. National Commission Public Health on Community Health Services. Cambridge, Mass., Har- communicable disease control 1961. Papers No 8, Geneva. vard University Press, pp 202-205. Health Organization, Prevention of Rh sensitization Jason, H 1970. The relevance of medical education to World Geneva. medical practice. JAMA 212:12. 1971, WHO Technical Reports No 468, context of his environment including the community and the family or comparable social unit. This implies that the new primary physician re- INVITED DISCUSSION bears the sponsibility of being the personal public health officer for each patient and family unit under his

care. It also implies a community responsibility of the primary physician heretofore delegated by default in Rugh A. Henderson many cases to the public health sector. The point is well taken by Dr. Treat that the new primary physician will have to take a “global view” to provide such services and counsel to his patient. The preventive medicine competencies and teach- Consideration of preventive medicine competen- ing resources presented by Dr. Treat in his discus- cies under four categories: primary prevention; sion of the education of primary care physicians secondary prevention, to include early disease de- delineate the common goals and potential resources tection; patient education; and community medicine of educators in this field. Although different methods provides a useful structure for delineating the core and unique settings guide individual training pro- of preventive medicine in the training of primary grams, one can readily identify with a fellow teacher physicians. Care must be taken to create the attitude of family and community medicine. The following that prevention, diagnosis, and treatment do not remarks will emphasize and expand on those princi- exist as separate patient care compartments. As ples and techniques found crucial by the Department pointed out in Dr. Treat’s paper, this leads to the of Family and Community Medicine of the Pennsyl- tendency for check-ups to be directed towards the vania State University College of Medicine in pro- detection of early disease rather than modification of viding preventive medicine input. risk factors to future health. Although the importance DETERMINANTS OF THE APPROACH of immunization against infectious disease cannot be questioned, emphasis on this important subject can The introduction of Dr. Treat’s discussion de- allow the neglect of other preventive approaches by scribes the impetus given to the current development the physician while enabling him to rationalize that physi- of educational programs for the primary care he is doing first-class prevention. The primary care cian by various national study groups. The thrust physician as stressed in the paper must bear respon- of these reports has been to encourage training of a sibility for the entire health situation. Each step new type of primary physician who would be re- taken should be justified as being a logical rational sponsible for advising, coordinating, and supervising approach to increase the patient’s survival as an in- patients’ medical care at points of entry into the dependent person. The analogy of the primary medical care system. This person would be a physi- physician as a good quarterback not independently cian who functions as a provider of primary care performing all functions of each play, but calling the and as a patient counselor and advocate at the signals also implies that the roles of the various patient-physician interface of the health care system. players be understood by him. This interface develops at different points depending In Dr. Treat’s discussion of education of the pri- on the orientation of the patient and the physician mary care physician, the family medicine program the various disease processes. In- in dealing with is utilized as a prototype. Inasmuch as I am currently care physician in creasing the role of the primary involved in devising a program to instill preventive instances shift- preventive activities implies in many medicine competence in the family medicine resi- ing of the patient-physician interface to a time earlier dents in the Department of Family and Community the various disease processes. in the natural history of Medicine at the Milton S. Hershey Medical Center, I This of course is the area of primary prevention and share Dr. Treat's familiarity with the programs in early secondary prevention (Leavell and Clark, the field of family medicine. 1965 ). An additional point emphasized in the paper is THE HERSHEY PROGRAM that the primary physician is one who accepts responsibility for a patient’s total health care within the The description of the Rochester Program pre-

61 62 / Prevention in Primary Care sents a useful framework for discussing the structure The Department of primary care programs. Although most con- The Department is actively involved in the training cepts mentioned have been central to the develop- of family medicine residents, medical students, and ment of the program with which I am involved, two types of new health professionals, the Medex, their expression has been shaped by the Hershey the physician’s assistant, and the Family Health situation and the processes employed. Reviewing the Specialist. The Medex Program is similar to the pro- Hershey Program in terms of environment, site, facil- gram initially developed in the State of Washington ity, data systems, patient population, and relation- (Smith, 1972). The Family Health Specialist Pro- ship with other departments is a useful method. gram is a master’s degree nursing program being The Setting developed in cooperation with the School of Nursing of the Pennsylvania State University. The Depart- The Milton S. Hershey Medical Center which ment is also involved in continuing education of includes a 350-bed hospital is situated at the western family physicians on a statewide basis. edge of Hershey, 12 miles east of Harrisburg in South Central Pennsylvania. The town of Hershey The Team and the surrounding Derry Township are a rural The model family practice suburban setting. The Pennsylvania State University centers are structured to emphasize the team approach to patient care. The College of Medicine admitted its first class in Sep- tember 1967. teams include first, second and third year residents and faculty The Department of Family and Community Medi- physicians. Medex and family health specialist faculty and students are also assigned to cine, organized in 1967, was the first clinical the teams. Nursing, department established. All departments are involved technical and clerical personnel complete the teams. Residents are to in vigorous development at this time. The Depart- encouraged work together with physicians’ ment of Family and Community Medicine has assistants and other allied health personnel. This involves the of worked to create interrelationships with other sharing roles in the care of the patient. health departments essential for a comprehensive program. The care teams are not rigidly structured; indeed There are two model family practice centers, one considerable vari- ation located exists in both personnel and experience levels in the Medical . Center and another about represented. 500 yards from the Medical Center in a student The function of the health care team should be apartment building. In the future there will be a such that response is determined not by the avail- unified model family practice center possessing all ability of physicians or other health care personnel the characteristics mentioned by Dr. Treat. but by the nature of the situation. In order for the The Department provides service to a large pro- team to function properly, the patient must be di- portion of citizens of Hershey and the surrounding rected to the proper member of the team to maxi- environs. Because this is predominantly a middle- mize quality and continuity of patient care and income, working class population, steps have been provide satisfaction. Comprehensive preventive med- taken to provide a more varied patient and com- icine can be practiced by the primary physician only munity exposure to the residents. An affiliation has if a reasonable degree of stability of relationships been developed with the Hamilton Health Center, a with patients is maintained. The team concept en- neighborhood health center in the lower- ables this to take place by providing additional socioeconomic area of north Harrisburg. In addition, receptor sites for the patient to interface with the the Pennsylvania State University is in the process primary care delivery system. This should tend to of developing a rural community health care delivery diminish the nonproductive transfer by the patient program at Millersburg, about 45 miles by road from one source of care to another. By means of from the Medical Center. The Department of Family weekly team meetings the model family practice unit and Community Medicine is serving as the primary teams work toward this goal as an integral part of responsible department in this effort. The teaching learning to deliver primary care. practice sites represent a spectrum of central Penn- sylvania primary care practice settings and patient The Data System populations. Full-time faculty supervision and community contact is a central theme for each setting. As in the Rochester Program a data system has Education in Family Practice/63 been developed in order to teach the resident the becoming more involved in understanding the prob- importance of considering patients as groups as well lems of their practice populations and their effec- as individuals. Patients are registered in the system tiveness in dealing with them. by name, address, and social security number. Also recorded are the marital status, religion, race, work The Preventive Environment status, sex, birth date, family status, educational The contention that the ability to scrutinize groups level, and number in the family. The geographical of patients and to compare the handling of particular location of the patient is established by a residence problems among different providers in the same and code which locates an individual by city, borough, similar situations is important to the training of a or township if he resides in the practice area. Patients primary physician is correct. This enables the pri- are also identified by patient care team and the mary care physician to develop a working knowledge physician they consider responsible for the manage- of elementary statistical principles and methods ment of their care. Such data makes possible the through experience with the patients in his practice. grouping of patients by single or multiple demo- The teaching of these concepts by a preventive graphic characteristics. A diagnostic index as de- medicine specialist can be expedited, if he has a scribed by Dr. Treat is used at Hershey to identify first hand familiarity with the primary care setting. problems dealt with at each patient encounter. Cod- This is best accomplished by being an integral part ing is done by a trained clerk using a modification of the residency training activities. By the same of the Royal College of General Practitioners Code. token, the primary care physician in training is most The coding is done directly from the medical record. likely to accept the importance of such concepts if The coding clerk also audits the adherence of the he has had the opportunity to apply and test them as record to the problem-oriented approach completing part of his primary care training. an important feedback loop. The willingness of the family medicine resident The data system has been developed in coopera- to become involved in assessing his quality of care tion with the Lancaster General Hospital Department and that of his colleagues has been supported by of Family and Community Medicine. Through the the experience of this author and Dr. Treat. Such use of the same computer service and programs the involvement provides another source of feedback to benefits of the community hospital approach and improve the quality of the problem-oriented ap- the university approach can be compared and con- proach to medical care. This involves describing a trasted. The Family and Community Medicine Resi- problem at its appropriate level of definition at the dency Program at Hershey considers development particular time which is important if the resident is of further ties with community hospital programs going to learn preventive aspects of care. Too often essential to its continued growth and the growth of the recording of the patient’s problem has been an the programs in community hospitals. all or none phenomena. The threshold for physi- A data system to enable the physician to learn cians’ recognition has been the existence of disease. from his practice is very important (Supplement to The problem-oriented approach has caused the Medical Care, 1973). The point made by Dr. Treat primary and secondary portion of the preventive that the construction of such a system in an estab- spectrum to appear as a more significant part of the lished practice is a formidable task would be strongly medical records. All the tools mentioned including supported by an individual who has been involved the master problem lists, titled, and code numbered in such an undertaking. The primary physician in progress notes, flow charts, immunization grids, and training must learn that the health profile of the health maintenance grids are important components total practice population should be considered of the problem-oriented record (Weed, 1969). equally with the health problems of the individual. Each primary physician should have a variety of Selection systems available to him during his training. The

Hershey Program offers both the manual and com- Selection of residents is a difficult task for any puter options to the resident physician. The avail- family medicine program. At Hershey as in Roch-

ability of a computer system with a coder has ester this is a joint effort involving residents and encouraged the residents to code for themselves. faculty. Applicants are seen by at least two faculty The computer system has stimulated their interest in members and one resident. The interviews are ar- 64/Prevention in Primary Care ranged to direct candidates who have specific resident conference is organized by the residents interests to faculty and residents who share these and directed by the chief resident. The usual format interests. Although attitudes towards primary care is a resident presentation with a guest consultant. in general and family and community medicine in This provides an excellent format for the introduc- particular are important considerations, so is the tion of preventive and community medicine input basic personality of the individual. The candidate's work by the faculty with background in the area approach to people and his interpersonal skills are and by representatives from the community. One key factors in determining his potential for the resident conference per month is devoted to resident program and family medicine. Physicians who are input to the program. This has also served as a fac- empathetic and interested in people have potential ulty forum for presentation of new ideas to the resi- for preventive medicine training. They wish to an- dent group for consideration. A weekly two-hour ticipate the problems of their patients to minimize psychiatry seminar is in the process of being the impact on their health. implemented.

Training Community Contact

The residency program is designed to provide Community medicine and research electives can core experiences while allowing a maximum of in- be taken to pursue preventive medicine, community dividual flexibility. Core rotations in the first year medicine, and health care delivery interests stimu- include two months each of internal medicine, lated by involvement in the core residency program. pediatrics, obstetrics and gynecology, surgery, and Experiences such as industrial medicine, prison one month of cardiology. Responsibilities of family medicine, public health agencies, health planning, and community medicine residents are identical to and community surveys are designed for residents peer residents of other specialties on these rotations. wanting more intense exposure in these areas. In

In the second year, core rotations include two many cases the resident is also able to maintain his months of inner city medicine at the Hamilton team role while so engaged. Health Center and two months each of inpatient The involvement of a consumer group in the psychiatry, emergency care, and pediatrics at Her- family medicine program at Rochester is an inter- shey. The third year program centers around the esting and positive development. Consumers must model family practice units with a potential of six be able to have significant involvement to maintain months available for electives. their interest. The demonstration of the value of di-

The first year resident assumes the direct care rect consumer participation is an important lesson responsibilities for approximately twenty families for the physician being trained in primary care. If within the context of the team. In addition to being he is going to be able to deal with his community assigned half a day per week in the family practice as a health care provider, he must be able to listen center throughout the year, the first year resident to people from disciplines and situations far different spends a full month with the team. The second year than his own. In the Hershey setting consumer in- resident spends at least two half days per week work- put is most effectively mobilized in an unstructured ing with his team. The third year resident, during fashion by the participation of patients in various his six months model family practice unit training, teaching activities particularly on the medical student expands his responsibilities in family care as a mem- level. Since second and third year residents are ac- ber of the team. Beginning with the second year tively involved in these programs they must cope level, residents are also involved in departmental with their patients away from the familiar office teaching programs for medical students, family setting. Additionally a different consumer type is health specialists, and Medex. Resource libraries demonstrated to the resident during his rotation at and a department document and curriculum center the Hamilton Health Center. provide resources for both the patient care and The position taken by Dr. Treat that preventive teaching role. medicine and primary care can and should be in- The importance of conferences cannot be under- separably linked can only be emphasized by ex- stated. The weekly team conference has already panding on this premise. The artificial division that been mentioned. In addition a weekly two-hour has existed between anticipatory (preventive) med- Education in Family Practice/65 icine and reactive (curative) medicine is no longer modification of the health care delivery system will acceptable. The new primary physician should be be accomplished. equally oriented to prevention as to dealing with disease. As a new health professional with roots in both general practice and public health, his training program must provide him with knowledge and REFERENCES techniques to function in this role. He needs an understanding of the processes by which a community deals as a group with its health problems. A team approach to care is required. The result is an in- Leavell, HR, and EG Clark 1965. Preventive Medicine crease in the ability to deliver preventive care, and for the Doctor in His Community, 3rd edition, McGraw Hill Book Co., 19-28. an increase in the flexibility of the practice allow- pp. ing the physician more time to become involved in Smith, RA 1972. Medex—An Operational and Repli- cated Manpower Program; Increasing the Delivery of analysis and management of the activity. Extension Health Services, Amer J of Public Health 62:1563-65. of the practice should be possible through the phy- Supplement to Medical Care, Vol. No. sician and through other members of the health care 11, 2, 1973. Sum- mary Recommendations of the Conference on Ambula- team into the community. The primary care physi- tory Medical Care Records, Report of the Conference on cian then becomes an active participant in his Ambulatory Medical Care Records, pp. 10-12. rightful community role as a health resource as well Weed, LL 1969. Medical Records, Medical Education, as resource. If a medical primary care residency and Patient Care, The Press of Case Western Reserve programs achieve this goal, then the proposed University, Cleveland. patients willing to present themselves to such an office for medical care.

What do we think we’re doing? First, INVITED DISCUSSION we’re getting the student in contact with the patient, and we think students choose medicine for this purpose. In other words, they want to take care of people. Secondly, we’re giving the student the chance to develop early Gordon Hall those frustrations which take those in practice 4 or 5 years to learn how to handle. These include more knowledge in preventive medicine, the operation of a health care system, the usefulness of a In commenting on Dr. Treat’s paper and the issue public health nurse, the method of getting a patient of programs for primary care training, I will briefly to a hospital, and other frustrating situations. By in- relate the philosophy and structure of the program troducing the physician to the patient and keeping at the recently founded Rockford School of Medi- him in contact with the patient, the physician de- cine. I shall be representing the ideas and work of velops what he considers important in preventive Drs. Dave McGaw, Robert Evans, and others, as medicine. A student cannot look at a patient with well as myself. By using existing health facilities and diabetic neuropathy, metatarsal heads sticking out manpower, the school is accomplishing its objective of the foot, and not wonder how the patient got that of preparing clinical medicine practitioners. The in the first place. After spending 8 months cur- education of physicians should be and can be cost- ing the patient, he’s not going to let it happen again. effective—funding of medical care education That patient and others with similar illnesses will through reimbursement received for quality care. get preventive care.

(Interestingly, this is becoming political gospel!) Finally, we want students to feel at the crunch Bob Evans (1973) has discussed the basis of these level about the patient’s concern. In essence, our concepts at some length in various documents. consumer feedback is simple— if they don’t like us,

Students come to Rockford after 1 year of basic they shy away, and they don’t pay us. Our feeling medical sciences at another medical school in Illi- is that a student will modify his behavior early in nois. They then spend 3 clinical years at Rock- his training if he gets such feedback. If he gets good ford. The curriculum during the first 2 years is feelings from his patients, if he’s doing something organized by systems taught in 4- to 8-week blocks right, he really cares and will continue to care. by those best qualified to teach them. For instance, We are attempting to do some of the things men- the G.I. tract might be taken by a couple of in- tioned by Dr. Treat, specifically, in the areas of ternists, a surgeon, a pediatrician, and others in- diagnostic coding and peer review experience. We terested in that area. All such faculty are drawn code all encounters, using the Royal College of from the ranks of private practicing physicians. The General Practice system. These data are then en- teaching takes place primarily in the physicians’ tered into a computer for ready retrieval. Its rele- offices. vance to the average family practitioner is question-

The last year is viewed as a transition from medi- able, however. The students are introduced to peer cal school to residency. During that year and for two review through participation in Saturday morning half-days a week of the preceding 2 years, stu- conferences where their charts and those of their dents work directly with practicing physicians in physician mentors are reviewed according to proto- their offices or in one of three community hospitals col. By the time the students graduate, they will as- located in the vicinity of the office practice. Practice sume that this is a healthy part of medical practice. offices involved in the program surround the city of Hopefully, they, in turn, will have the interest to do Rockford, covering the four points of the compass. as Bjorn and Cross (1970), and have outside ex- Three of the four sectors of the community had no perts consult in evaluating their practices. medical care whatsoever when our program started. Clearly, our students do not enjoy the breadth of Now, the school has opened offices in buildings innovative experiences described by Dr. Treat in the vacated by physicians. I run one of the office prac- Rochester program—the health care team, etc. I tices. Our patient panel, if you will, is that group of don't know whether that is good or not. I do know

66 Education in Family Practice/61 that the small town physician or primary care physician generally does not enjoy those advantages. REFERENCES Our program, by its nature, questions what model should be constructed. Should it reflect that nirvana

that we all hope for in the year 2015, with the multi- Bjorn, JC and HD Cross 1970. The Problem-Oriented discipline health care team, or should it reflect that Private Practice of Medicine. Chicago, Modern Hospital which the student physician is most likely to en- Press. counter when he returns to his hometown to put into Evans, RL, JG Pittman and RC Peters 1973. The com- practice what he has learned? We have chosen the munity-based medical school— reactions at the interface latter. If the student can survive in this situation, between medical education and medical care. N Engl J of learning primarily to rely on his own wits and skills, Med 288(141:713-719.

he’ll be well-equipped to survive in Moline, Illinois, or any of the other towns of a few thousand people, which are crying for physicians. must work through. It’s not unrealistic to ask students and residents to also work through that or- DISCUSSION ganization to obtain certain services for their patients. If they find they are frustrated by inade- quacies in that organization, we think they’ll suggest

changes in the future to see to it that the community

in fact bootstraps itself. ABRAMS: Have you considered organizing pre- PAYTON: The last description of the Rockford paid arrangements which might encourage delivery situation reminds me that I was going to mention of preventive services? something about practice management knowledge HALL: Not at present. following Dr. Baker's presentation on curriculum. A ABRAMS: Do you see that as something you necessary factor, economics of health service de- need to do to help in all the things we’re talking livery, was omitted. In light of economic considera- about? tions, I find the teaching situation in Rockford ap- HALL: That is being discussed. But at the mo- palling because of the well-known difficulty in ment, in northern Illinois, there is no model prepaid financing, hence delivering, any kind of preventive plan. The closest we can come to it is a Chrysler services out of the fee-for-service base, out of the assembly plant in which the union has arm-twisted office-generated income. Blue Cross into providing practically all aspects of Returning to the topic of preventive medicine and in- and out-patient care and prescriptions.

Dr. Hall’s comments about no ideal approach to the STOKES: The irony of the situation is that going training situation, I would say that unless we can to HMO prepayment may not necessarily do what demonstrate to students that there is a possibly new you would like. One of the first things that has been and better way of doing things, they won’t go into happening in California in HMO’s in their attempts practice knowing how to improve upon the old to operate at reasonable costs is they are negotiating model. away certain services. Preventive services are usu-

I’d like to have a psychologist available to do a ally the first thing to go. So just switching delivery lot of things with my patients: to prepare parents and financing mechanisms doesn’t necessarily insure for child rearing, for example; to assist me in the that you are going to have preventive services evaluation of emotional problems, et cetera. Yet, automatically built into your practice. It has to be how am I going to pay the office expense of that something that is institutionally supported more psychologist when he’s not reimbursable under than just through financing. Blue Cross-Blue Shield? KISSICK: Two comments on financing: First, FARLEY: For clarification, I would like briefly to the President (Nixon) sent his health message to outline the financing of the Rochester family medi- the Congress yesterday (February 20, 1974). I cine program, since I used to be a doctor and now I found most fascinating that the New York Times hunt for money to keep us going! For a yearly budget identified in its lead that the President speaks out on of roughly $800,000, I have to find about $300,000 health care costs, and the Washington Post in its lead a year above and beyond what we generate from identified the President’s determination to redis- fee-for-service practice ($200,000) and third party tribute physicians geographically, by specialty, and payments ($300,000) for the in-patient care that specifically, to bring about more family physicians. the residents provide. He’s to pursue the latter by restructuring the ABRAMS: Dr. Hall, do you have a response to financing of medical education.

Dr. Payton’s comments? Man is a rational animal, an emotional animal, HALL: As pointed out, we have the feeling that and many other things, but he’s also an economic preventive medicine ought to and can be pervasive animal. My guess is that a severe restructuring of in the clinical setting as part of good medical care the financing of medical education by the Congress within the existing health system. For certain pre- of the United States would bring about rather ventive services, we have available a local public dramatic change. health department. This is the same health depart- In medicine we look around to find how things ment that the other physicians in the community are done. The whole Flexnerian phenomenon is so

68 Education in Family Practice/69 extraordinary because one man examined all the that won’t sell in traditional ways. Seat belts never medical schools in the United States and Canada sold through the power of personal persuasion. and concluded that one was adequate, and the path Congress passed a law, and now everybody that for medical education was for everybody to replicate buys a car buys a seat belt. It’s a preventive that one. When the report was finally fully imple- measure. mented by about 1960, almost all schools looked We, as physicians interested in preventive medi- like Johns Hopkins did in 1910. We may soon have cine, agonize over the fact you can’t make any head- an analagous experience with primary care if the way with smoking, with diabetes, or obesity or hy- society really puts the lever on us. pertension. One of the drug firms has developed

I say this because I sense that the leaders in fam- what they call Project Health, a program aimed at ily medicine and preventive medicine are here gath- modifying lifestyle, changing dietary habits, stopping ered. If Congress moves forcefully in this direction, smoking and so forth. Corporations are buying it and people are going to be looking to us and paying us encouraging their executives to enroll. Why? Be- for answers that go beyond where experiments have cause the corporation realizes that if an executive carried us. vice-president drops dead in his job, it costs them Having said this, I’d like to try to offset my earlier $175,000 to replace him. long-range pessimism with some short-range opti- It's fascinating to see all over the campus at the mism regarding financing and the delivery of pre- University of Pennsylvania placards for anti-

ventive services. smoking clinic. The fee is $100. If you attend the

Many of the problems which have been raised 6-week followup and pass the test, you can get fifty about financing, prevention and so forth, can be bucks back. Reimburse fee mechanism.

solved if we move beyond the scriptures and the I’m suggesting that there are a lot of directions

gospels. I have been as guilty as the rest of you in which things are going, and there are going to

around the table in writing these. I like to think I’m be multiple option strategies that we’ll find our- the St. Paul of the movement. In these, we really selves in the midst of, and we’re going to do some fall back on our druthers rather than asking some things that we may not like in terms of our values, rather bold and embarrassing questions of ourselves but which nonetheless achieve the preventive ends and the system. which we espouse. We are a pragmatic society. We There’s been a very refreshing influx of econo- will respond to certain kinds of incentives, particu- mists in the last few years who are beginning to ask larly economic ones, and we've not looked at that some of these questions and are beginning to point very imaginatively in our health care plans. We’ve out some things about distribution of manpower and been fairly pedestrian, saying, “It’s either fee-for- utilization of services and trade-offs that the con- service or prepaid group practice.” There are lots

sumers will make and how you deal with problems of ways of mixing it.

DISCIPLINES

This section, in two parts, focuses upon those disciplines and areas of expertise in preventive/ community medicine which are of particular relevance to primary care practice and hence to primary care educational programs. The first part deals principally with various applications of epidemiology and quantitative skills, while the second part emphasizes application of social and behavioral sciences to a variety of community health problems encountered in practice.

Dr. Stokes first differentiates between those preventive medicine strategies suited to delivery in the personal health service setting and those not so suited. The paper then discusses the need for and use of various forms of clinical, evaluative, and operations research in primary care. Dr. McWhinney’s discussion emphasizes the important contribution of epidemiology especially in establishing primary care departments on sound intellectual foundations. “Tactical” and “strategic” applications of epidemiology to primary care, as well as epidemiolog- ically-based research in the Department of Family Medicine at the University of Western Ontario, are described. General discussion iden-

tifies the need to develop physicians with combined expertise in both the measurement sciences of preventive community medicine and in primary medical care in order to provide the appropriate teaching and

research resources for primary care programs. Attention is given to questions of financing and training of such persons.

Drs. Falk and Scutchfield’s paper first depicts the contemporary primary care movement as a social phenomenon, resulting from concerns of some health professionals, other health workers, consumers, and legislators. It becomes incumbent upon the primary care provider to have knowledge of and methods for working with those social institutions and phenomena which relate to health service delivery. The core disciplines of community health are described; namely, biostatistics, epidemiology, environmental /occupational health, health services administration, and health education. Some pertinent aspects of social science, economics, and politics are discussed. Dr. Scutchfield’s formal discussion complements the lead paper by highlighting the special role for community medicine departments to play in applying their spectrum of disciplines to assessing health prob- 12/Prevention in Primary Care

lems and health service needs—“community diagnosis.” Often, the findings of such assessments will be directly applicable in the development of primary care services and accordingly should be well understood by primary care providers. The general discussion touches on several ways that community diagnosis and primary care might interact. 4 vaccine-associated poliomyelitis, allergic reactions to prophylactic antibiotics and the complications of

oral contraceptives. It has been wisely written PREVENTIVE STRATEGIES, primum non nocere, and although patients usually RESEARCH AND EVALUATION accept troublesome side effects of therapeutic agents, IN PRIMARY CARE they are less tolerant when preventive interventions

cause disability and death. It is for this reason that we need to calculate and consider such trade-offs as precisely as possible. III Joseph Stokes My second premise is that the preventive attitude should pervade every aspect of clinical medicine. The objectives of both preventive and clinical medicine (and most certainly primary care) are the same, INTRODUCTION namely to maintain and restore health. Therefore, both prevention and therapeutics share a common Although Dr. McWhinney and I have been asked goal; it is only the strategies that differ. Unfortu- to focus our remarks on the subject of evaluation nately, we suffer from the lack of an operational and research in primary care, I am going to begin by definition of health to use as a guide to attain this listing a few premises related to both the practice goal. For instance. Dr. J. W. Bush (1975) has and teaching of preventive medicine. After stating been developing a two-dimensional definition of these premises, I will then review the general strat- health with functional status on the ordinate and egy by means of which prevention is implemented, time as the abscissa. He defines and evaluates a series particularly as it relates to primary care. Finally, I of functional steps ranging from full physical and will return to our assigned task by presenting the social function without symptoms at one extreme to evaluation model and suggesting a few problem death at the other. He then calculates the transitional areas ripe for research by those concerned with im- probabilities of moving from any existing level of proving the practice of primary care. I will also function (at T0 to all other levels at some future suggest how epidemiologic methods can help to ) time (Ti). This latter represents a prognostic di- solve such problems. mension and the factors which determine these transitional probabilities do not necessarily affect

PREMISES functional health status at T0 . For instance, hyperlipidemia, per se, does not affect function but

My first premise is that the practice of preventive it does help estimate the probability of developing medicine is substantially more difficult than is clini- coronary heart disease and other manifestations of cal medicine. The clinician almost always deals with atherosclerosis which will affect function at a later patients seeking help in solving health problems, time. many of whom need little more than a sympathetic In one sense, my third premise is a corollary of ear. The practice of preventive medicine, at least the first: Since preventive medicine is so difficult it within a clinical context, demands that both patients requires generous resources and strong institutional and physicians act to avoid anticipated but as yet support. Physicians should not necessarily expect unfelt events. Unfortunately, it is much easier either their patients to stop smoking even after a passionate to deny or accept the risk of potential catastrophes presentation of the compelling facts. Dr. John Far- than it is to avoid them, particularly when such quar and his associates (Beyers, 1974) have shown avoidance depends upon change in entrenched pat- that group counseling by specially trained behavioral terns of behavior such as cigarette smoking. Preven- scientists is the most efficient means of effecting such tive medicine is further complicated by the fact that change thus suggesting that specialized smoking one is almost always faced with difficult trade-offs withdrawal clinics may represent a new institutional between the risk of developing disease and the ad- requirement of the practice of preventive medicine. verse side-effects of preventive procedures such as Obviously, such clinics will cost money which as yet

73 7A/Prevention in Primary Care cannot be recovered through third party reimburse- ing back these pages of public health history. Prohi- ment. Although an ounce of prevention may be bition clearly reduced the incidence of cirrhosis of worth far more than a pound of cure, society still the liver and undoubtedly had other favorable ef- finds it difficult to act according to this ancient fects; nevertheless, society concluded that its net adage. As a result, it is much easier to muster the effect was negative and that other means should be resources for the surgical management of carcinoma used to control the excessive use of ethanol. One of the lung than it is to prevent the disease in the can anticipate the hue and cry were the United first place. Firefighting has a far stronger emotional States to legislate prohibition of the production and appeal than does fire prevention, and the resources consumption of cigarettes. Nevertheless, we have required by the health system are not allocated by far from exhausted the health benefits that can be primarily rational criteria. gained through environmental manipulation, and

My final premise is that the marriage between public attitudes do change. For instance, smoking, al- community, preventive, and social medicine on one coholism and other forms of drug abuse all represent hand and family medicine and primary care on the various forms of coping behavior. other is a very healthy one. Both disciplines have Cassel (1974) and others have suggested that so- much to contribute to the other. I feel so strongly ciety should pay more attention to crowding and on this point that both functions are currently en- other aspects of the social environment. The elimi- compassed within a single department at the Uni- nation of poverty might well represent a milestone versity of California, San Diego; approximately comparable to the cleansing of central water sup- one-third of the medical schools in the United plies. However, it will be much more difficult and States which have family practice programs have require much more money to accomplish. As Geiger analogous organizational arrangements (ATPM, points out, residents of both the urban and rural 1974). ghettos need “bread” far more than medicine, and medicine should never contribute to either the ro- PREVENTIVE STRATEGIES manticization or institutionalization of poverty. Geiger demonstrated at the Tufts-Delta health care Environment program at Mound Bayou, Mississippi, how an innovative health care system could not only provide The term, public health, was first used by Wolf- health care services but could also catalyze certain gang in Rau 1764 (Rosen, G., 1958) and the 200 improvements in the social, economic and political years since that time have taught us that the most environment oppressing his patients. He also found effective means of preventing illness is by altering that health care has its limits as a power base from the environment rather than modifying the host. By which to effect such social change. Whenever pos- and large, such environmental interventions have sible, practicing physicians should be agents of so- been implemented by exercising the legislative and cial change, and the annuals of medicine are replete regulatory power of the state. The decisions to with such acts of courage as exemplified by John chlorinate common water supplies and to pasteurize Snow removing the handle from the Broad Street milk were basically political rather than medical de- pump. cisions and practicing physicians often did as much to hamper as to help their execution. To this day, the Host easiest means of obtaining raw milk in the State of

New York is by obtaining a physician’s prescription. The other major preventive strategy acts to di- Regulations controlling food handling, housing and rectly protect the host. This is what I mean by the highway construction, and automobile design repre- term, clinical preventive medicine, and what Drs. sent other in ways which we have reduced environ- Schneiderman and I have recently summarized in mental risks to health. Unfortunately, the most a chapter of A Textbook of Family Practice (Stokes efficient manipulations have already been made. and Schneiderman, 1973). Fortunately, some of What’s more, there are limits to what society will the newer models of delivering comprehensive tolerate. Some still find chlorinated water distasteful health care represent fresh opportunities to synthe- and others steadfastly prefer raw milk, although size preventive and therapeutic medicine. Although neither represent a political force capable of turn- it is beyond the scope of this discussion to review Strategies, Research and Evaluation /75

each method in detail, I will summarize below each 1972). More effective methods of treatment have of the major categories. also added increased importance to screening for

Health Education: First of all, the physician diseases such as essential hypertension. However, should impress upon all of his patients that most we should be rigorous and selective in deciding adults serve as their own physician most of the time which tests should be applied to which age, sex and and that it is only under exceptional circumstances other special risk groups, always keeping in mind that they turn to health professionals for advice. that we seek the remediable, and as yet unrecog-

Therefore, it follows that patients should be in- nized, disease and risk factors. structed not only regarding good health habits for Immunization: Specific immunization is the clas- themselves and their dependents but should also be sical method of clinical preventive medicine de- given first aid instruction and informed of those signed to protect the host against anticipated symptoms that warn of the presence of early and exposure to infectious micro-organisms. Despite the remediable disease. Finally, they need to be taught routine and ritualistic administration of these vac- how and when to call upon the health care system cines, their proper use requires a great deal of for help when needed. knowledge regarding the agent, host, vaccine and More selectively, certain patients with chronic the natural history of the disease. In every case the diseases such as hypertension, coronary heart disease decision as to whether or not to vaccinate any and chronic obstructive pulmonary disease should given patient at any given time is based upon a be instructed as to how they can help in their own balance of risks as I have discussed above. management. For instance, more physicians should Immuno-, Chemo- and Antibiotic Prophylaxis: copy Dr. Kenneth Moser ( 1973) who runs a course There is a growing list of special circumstances call- for patients with chronic pulmonary disease at the ing for administration of immunoglobulins, antibi- University of California (San Diego). He has dem- otics and other drugs to effect both the primary and onstrated that those so instructed not only function secondary prevention of a broad spectrum of dis- better but also utilize fewer health care services dur- eases extending from rheumatic fever to thrombo- ing the course of their illness. We should be doing embolic disease. The value of such prophylaxis is the same for those patients with coronary heart dis- well established for some of these circumstances. ease and for those suffering from other chronic Unfortunately, abuse persists and it has been demon-

diseases. The sick patient is the world’s best moti- strated that such prophylaxis is either of no benefit vated student and we should take full advantage of or actually detrimental in many circumstances. this fact. Therefore, the clinician should maintain an attitude Unfortunately, few data are available as how best of responsive skepticism to new protocols as they

to effect health education. It is clear that different are proposed. patients learn in different ways and that our ap- The Prevention of Pregnancy, Childbirth, and proaches should vary according to age and socio- Congenital Defects: The advent of oral contracep-

economic status. It is also clear that certain patients tives, genetic counseling, amniocentesis and chang- are better motivated to engage in such health edu- ing social attitudes has resulted in the very rapid cation behavior, but we need far better data regard- development of a new facet of clinical preventive

ing these points. medicine of which all primary physicians should be

Health Screening: After an initial wave of over- well aware. It has been recently estimated that 40

optimistic enthusiasm we are gradually developing a percent of all mental retardation can be prevented better balanced and rational view of health screen- through the application of proper maternal nutrition, ing. As the recent series of articles in Lancet avoidance of teratogenic drugs and other agents (Whitby, 1974) demonstrates, there are patients with (e.g., rubella), selective abortion based upon amnio- unrecognized and remediable diseases and risk fac- centesis (e.g., Down's syndrome), and the early tors that can be identified and treated more effec- recognition and proper management of a few rare tively during their presymptomatic phase (e.g., diseases such as phenylketonuria and galactosemia carcinoma of the cervix). Such tests as the cervical (Stein, 1975). All of these procedures should be an smear cytology have already been well accepted into integral part of primary care; we should no longer

the practice of primary care although healthy debate depend upon local health departments to fill the

as to their effectiveness and efficiency persist (Yule, gaps that still exist in clinical preventive medicine. 16/ Prevention in Primary Care

EVALUATION AND RESEARCH we have about the clinical method after all these years. The work of Elstein and others at Michigan Finally, I come to the subject originally assigned, State represents an example of what can be done that of evaluation and research in primary care. (1972). I’m also impressed with what Smith and

First, let me make clear that I do not use the words McWhinney ( 1975) are doing in studying how fam- evaluation and research interchangeably. I believe ily physicians make diagnostic and therapeutic that there is a clear distinction between the two. decisions as compared with internists.

Evaluation should always be applied to any impor- The second important research priority is the de- tant task to determine whether or not the goals and velopment of better health information systems. We objectives were ultimately achieved. The means by must analyze critically the information upon which which such evaluation is to be carried out should be we base clinical decisions and learn to manage such planned in advance not only to assure that objective data more efficiently. Information must be available and predetermined criteria will be used for evalua- to effect decisions. If it’s stored in the stacks of a tion but also to assist the planning process in library, it will not bear on decisions made on the establishing explicit and precise goals and objectives. wards. Only if it is accessible can it have any influ-

The evaluation process is to set goals, defining them ence on the actions that we take. On the other hand, in measurable terms. Then determine how closely we have a great deal of information cluttering up these goals can be achieved. Unfortunately, one our medical records which is trivial and not useful usually falls short of achievement, thus leaving a gap. in any way (Stokes and Hayes, 1970). Here is Some kind of action to correct these deficiencies can where the algorithms required by computers can be then be taken. helpful. Fortunately, computers are so simple-minded

Research is different in that it poses questions at that they need precise instructions at every step of a higher level of significance, the answers to which their logic. The discipline required to write such pro- have wider application and often represent a true grams should be very useful to physicians. Obviously, step forward. At the moment, the family medicine if you feed a computer garbage it will spit it right movement is being swept along by a wave of social back at you. It is not a sieve, only a speedy work- concern not unlike the community medicine move- horse. If your data isn’t clean and crisp the comment of the 1960’s. A movement is not a rational puter can’t help either clean it up or tighten logic. process but a gut reality. Having ridden the crest A third research priority relates to the need for of the community medicine wave, I would caution more and better clinical trials, including those which some of you as to the hazards as well as the thrills. compare preventive strategies. A classical clinical

One of the things that particularly concerns me is trial selects a cohort of patients, then randomizes its that the family medicine movement has taken an subjects between an intervention and a control anti-intellectual twist which is, therefore, also group. Intervention is then undertaken holding the anti-research. One of the reasons that I am pressing control group as constant as possible. Outcome and so hard for the melding of family and preventive process criteria are then compared. For instance, at medicine is that classical academic preventive medi- the moment there is a 30 million dollar annual in- cine has been a little too precious, intellectual, vestment in the Multiple Risk Factor Intervention iconoclastic, conceptual and isolated from the real Trial and the more selective programs of the Lipid world. On the other hand, as previously stated, the Research Clinics and Hypertension Detection and family medicine movement is leaning in the oppo- Followup studies of the National Heart and Lung site direction. My hope is that a close relationship Institute. The general objectives of these programs between the two will bring them both into better are to identify patients at high risk of developing balance. coronary heart disease and other complications of What then are the questions which family medi- atherosclerosis and then to randomly allocate such cine research would try to answer? I’m going to subjects between intervention and control groups. The present four general examples, but I do not pretend logic is simple but the logistics are horrendous. that my list is complete. Such experimental techniques also present prob-

My first suggestion is that family medicine can lems. They are clumsy in that they require so many improve our understanding of the clinical method. carefully selected and cooperative subjects. It is also

It is remarkable how little systematic information difficult to maintain double-blind design and the Strategies, Research and Evaluation/ll findings are often difficult to translate back into the their preventive as well as diagnostic and therapeu- “real world” of medical practice. There are also tic strategies. vexing ethical problems regarding nonintervention as it relates to the control group. Fortunately, other methods are now available including the continued development of multivariate analysis which can be applied to observational, nonexperimental settings. REFERENCES The advantage of these techniques is that they can be much less disruptive. For instance, the Framing- ham Study set down at the beginning approximately

25 explicit hypotheses from which it was later able Association of Teachers of Preventive Medicine Survey of to define coronary risk factors without any interven- Departments of Preventive-Community Medicine in U.S. tion whatsoever (Dawber et al., 1964). A current Medical Schools, 1974. Newsletter 21:10-14. example, which is perhaps more closely related to Beyers, CK 1974. Can health habits really be changed? primary care, deals with emergency medical serv- Prism, May, p. 13. ices. Here again, Dr. Bush and his associates have proposed using functional health status as the de- Bush, JW 1975. Health Indices Outcomes and the Quality pendent variable on one side of the equation and a of Medical Care. In Evaluation in Health Services De- host of independent variables on the other. For in- livery. R Yaffe and D Zalkind (eds). New York, NY, stance, one can evaluate the size of the hospital, Engineering Foundation, pp 313-39. the amount of training of its personnel and many Cassel, J 1974. Psychosocial processes and “stress:” The- other factors in order to determine how they relate oretical formulation. International Journal of Health to health outcome. Hopefully, such analyses will al- Services 4:471-472. low us to explain most of the variance in health outcomes among different emergency services. Al- Cochrane, AL 1972. Effectiveness and efficiency: Ran- though there are several assumptions in the use of dom reflections on health services. London, The Nuffield such a method, they are not as restrictive as has Provincial Hospital Trust. been classically assumed (Bush, 1975). Such tech- Dawber, TR, WB Kannel, PM McNamara 1964. The potential applications to niques may have many prediction of coronary heart disease. Transaction of asso- health services research, particularly as it impinges ciation of life insurance medical directors of America. on primary care. 47:70.

Elstein, AS, N Kagan, LS Shulman, H Jason, and MJ Loupe CONCLUSION 1972. Methods and theory in the study of medical inquiry. J of Med Ed 47:85-92.

In conclusion, I would merely restate that it is Moser, K, EM Shibel, and AJ Beamon 1973. Acute very doubtful that clinical medicine, in general, and respiratory failure and obstructive lung disease: Long the primary care, in particular, will ever represent term survival after treatment in an intensive care unit. optimum context within which to practice preven- JAMA 225:705-707. tive medicine. Nevertheless, practicing primary phy- Patrick, DL, JW Bush, MM Chen 1973. Toward an sicians already have available to them many ways operational definition of health. J of Health and Social of effecting both primary and secondary prevention Behavior 14:6-25, March. which are of proven benefit and highly efficient when compared with the traditional diagnostic and thera- Rosen, G 1958. A history of public health. New York peutic management of symptomatic disease. Devel- MD Publications. oping systems of health care represent a fresh op- Smith, DH and IR McWhinney 1975. Comparison of the portunity for physicians not only to incorporate es- diagnostic methods of family physicians and internists. tablished preventive methods into primary care but J of Med Ed 50:264-270. also to systematically evaluate their effectiveness and efficiency (Cochrane, 1972). Primary care physi- Stein, ZA 1975. Strategies for the prevention of mental cians should also engage in research to improve retardation. Bull of NY Acad of Med 51:130-142. 18/Prevention in Primary Care

Stokes, J III and L Schneiderman 1973. “Preventive biomedical information system. J of Med Ed 45:243-249.

Medicine” In Textbook of Family Practice. Conn, A Whitby, LG 1974. Screening for disease: Definition and Rakel Johnson, eds., Philadelphia, W.B. Saunders Co. and criteria. Lancet 2:819-821.

Stokes J III and RM Hayes 1970. A commentary on the Yule, R 1972. Acta Cytologica 16:389. The primary physician uses two preventive methods: the tactical and the strategic. In the tactical method, he applies his knowledge of health risks to INVITED DISCUSSION the patients who are consulting him for all kinds of problems. Since, in the course of one year, most of his patients will consult him for one reason or an-

Ian R. McWhinney other, he has a superb opportunity for identifying patients who are at special risk and for picking up asymptomatic disease. In order to apply this method with the greatest economy, he needs the knowledge of

I should like to begin by taking up a point made by risk and of the natural history of disease which Dr. Stokes: the risk that family medicine may become clinical epidemiology can give him. a “gut feeling” rather than an intellectual pursuit. In the strategic method, he applies this knowledge With departments and programs developing at such to the whole population of his practice. For example, a rapid rate, I see this as a very big risk. he may decide to screen all adults between 25 and 65 We can learn a very useful lesson from what hap- for hypertension. We have hardly yet begun to apply pened in the education of teachers. In his book this method in North America, although it has been Crisis in the Classroom, Silberman (1971) describes used for some years in the United Kingdom, where how the education of teachers became separated from the National Health Service provided general practi- the academic mainstream, cut off in teachers colleges tioners with a ready system for defining their prac- from its academic roots in philosophy, literature and tice populations. There is, however, no reason at all history. As he went round from one teachers college why we should not apply the method here. The main to another, Silberman found a monotonous pattern obstacle is not one of organization, but one of atti- of superficiality, triviality and intellectual ossifica- tude. Primary physicians have not until recently tion. thought beyond the individual to the population of

This is a cautionary tale which we would do well the practice as a whole. A primary doctor’s prac- to ponder. I think it is very important that, in this tice should be regarded as a population at risk, with period of rapid growth, we ensure that the intellectual subgroups who are at special risk and require atten- foundations of primary care are well laid. This I see tion even if they are not at the time attending the as the greatest benefit from the marriage between physician. preventive medicine and family medicine. Epidemi- Now I want to describe how we have tried to apply ology is the basic science of preventive medicine. I some of these ideas at the University of Western think we can identify epidemiology as one of the Ontario. When family medicine started there 8 basic sciences of family medicine as well. years ago we were one of two divisions in a depart- Of course, we in family medicine have other aca- ment of community medicine. The other was epide- demic roots: in the behavioral sciences, in the miology and preventive medicine. Four years ago we humanities, and—like other clinical disciplines—in became, by mutual consent, two separate depart- the biological sciences. ments. It was an excellent way of introducing a new Our knowledge is applied—as Dr. Stokes has told discipline to the medical school. us—through the two major strategies of environmen- Our first tasks were to set up model teaching tal engineering and host intervention. Environmental practices, to develop an information system, to

engineering is the province of the public health launch an undergraduate teaching program, and to worker: the doctor who deals with populations rather develop the postgraduate program which had been

than with individuals. The primary physician prac- in existence two years. In all these tasks, but particu-

tices preventive medicine mainly through the indi- larly in the first two, we were in constant communi-

vidual. The distinction is useful, but should not be cation with our colleagues in epidemiology. considered absolute. The primary physician is also We confronted the denominator problem and de- concerned with the health of populations, but his cided to go for a defined population for each of our

focus is more on small population groups such as the three model teaching practices. We did this by de- family or work group, or the population of his prac- signing a family data sheet and recording demo-

tice. graphic data about every family registering with our

79 80/ Prevention in Primary Care practices. Having done this we set about designing How can we encourage research in departments of a system for collecting data on every patient en- family medicine? I think it is essential that we don’t counter in the centers. We now have over a year’s rely entirely on epidemiologists to do the research. data and have been through the laborious process of It is equally important that research is not seen as 1 checking and validating it. Samples of descriptive something which is carried out by specialized per- epidemiology from this data are shown in Appendix sonnel in one corner of the Department. The spirit

I, this chapter. of inquiry should be something that pervades the

Although the methods used, and the data obtained, whole Department and affects all members of it in will be of general use and interest, our chief purpose some way or another. in setting up this system was not research with a In our Department we have one family physician big “R.” Its chief purpose was educational: to pro- working virtually full time on research on a grant vide staff and residents with continuing feedback from the Federal Government. We have had two about their performance, to give us information visiting professors—each for 12 months—under the about the content of family practice, and to help us to Federal Government visiting scientist program: Dr.

evaluate the work of the practices. It has also, of D. F. Crombie from Britain and Dr. B. G. Bentsen course, provided data for research, helped us with from Norway. All of these have contributed greatly management decisions and given us a basis for the to the development of our research activities. I be- application of strategic preventive methods. lieve that our most important achievement, however,

It is important to emphasize here a point made by is to have so many members of the Department ac- Dr. Stokes. The collection of data does not constitute tively engaged in research under the aegis of our research. Research begins with an idea—a question research committee. —followed if necessary by the collection of informa- It is important that funding agencies recognize the tion. We should not collect large masses of informa- need to support people like this in departments of tion and expect research to grow miraculously from family medicine. The most important thing, however, it. Of course, we must collect data for other reasons is not material resources but the intellectual climate. —-education, audit, management—but we must al- Let us not forget that most of the original work in ways be clear about our objectives for doing so. general practice has been done in Great Britain by Every new discipline begins with a phase of data working general practitioners with minimal resources collecting. In due course, however, this must be fol- (Research Projects by General Practitioners, 1974). lowed by the generating of ideas and hypotheses Having established a climate favorable to the devel-

about the data. In primary care we are almost at the opment of ideas, all a department needs to do is to end of phase one: our greatest need is not more in- establish a system by which a creative individual can formation but new thinking about the information receive the maximum of support, encouragement and which is already available. constructive criticism. This is what the marriage of

Research in our department has arisen from ques- faculties of preventive and family medicine is all

tions which we wanted to answer : about the about. incidence and prevalence of disease in general practice; about the structure and function of the primary health care system; about the natural history of presenting complaints; about the problem-solving REFERENCES strategies used by family physicians; about the efficacy of our practices and our educational programs.

A resume of work in' progress is given in Appendix Research Projects by General Practitioners: A selected bibli- II, this chapter. There are many problems awaiting ography 1974. London. England, privately published study by primary physicians, especially in the natural by the Royal College of General Practitioners. history of disease and the evaluation of therapy.

Silberman, Charles E 1970. Crisis in the classroom, the

1 The development of the information system was financed remaking of American education. New York, Vintage by a grant from the Ontario Ministry of Health. Books. APPENDIX I

Samples of Descriptive Epidemiology from the Patient System Department of Family Medicine University of Western Ontario

TABLE 1. Annual Incidence of New and Recurrent Attacks of Otitis Media Per 1,000 Patients by Each Age Group and Sex

Age 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-69 70 + Total

M 276 133 31 20 26 10 9 16 9 0 0 54

F 330 135 62 25 22 14 19 0 13 0 8 51

T 300 134 46 23 23 12 14 7 11 0 5 52

TABLE 2. Average Number of Visits For Each New or Recurrent Attack of Otitis Media by Age Group and Sex

Age 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-69 70 + Total

M 2.03 1.64 1.50 1.40 1.88 1.67 3.00 1.00 2.00 0 0 1.84

F 1.57 1.62 1.44 1.44 2.00 1.80 1.14 0.00 4.00 0 3.00 1.66

T 1.80 1.63 1.46 1.43 1.95 1.75 1.70 2.75 3.33 0 3.00 1.74

81 82/Prevention in Primary Care

UgiNftRV tRRct /kFcTctip< he3>icQl 1973 fiftn&trs ahth one fiode- ^rPisoj>ei

U) MAKS’

PtOl(\L£

oocv

J.VV

fi&e /n ygpios

Figure 1. Age and Sex Distribution of Patients with Urinary Tract In- fections. St. Joseph’s Hospital Family Medical Center, 1973. Patients with one or more episodes. APPENDIX II

Department of Family Medicine University of Western Ontario

Publications and Work in Progress (completion date in brackets)

1. Research in Progress

Bass, M.J., Newell, J.P., Williams, J., Warren, S. Evaluation of a Rural Health Centre, (1977). Bass, M.J. An Analysis of Patients’ Symptoms over Ten Years, (1976). Bass, M.J. The Division of Primary Care in an Urban Centre, (1977).

Bainbridge, J., Brennan, M., et al. Early Post-Partum Discharge Using Home Care, (1978). Brennan, M., Dungal, L., Stewart, M. Evaluation of Family Medicine Graduates, (1977). Dickie G.L., Bass, M.J. Evaluation of Residents in Community Practices, (1976).

Hartwick, K. A Technique for Increasing Follow-Up in Otitis Media, ( 1976). Mansworth, C. Medical Audit of Newly Diagnosed Hypertensives, (1976). Newell, J.P., Brayford, B. The Independence of The Family Practice Nurse, (1977).

Sherin, J., Bass, M.J. Evaluation of Residents in Community Practices, (1976). Stewart, M. Interpersonal Aspects of Primary Care, (1977). Suveges, L., Newell, J.P. The Effectiveness of Pharmacist Contact, (1976).

2. Research Completed But Not Yet Published

Bass, M.J. Patterns of Primary Health Care in London, ( 1975). Bass, M.J., Bentsen, B.G. The Role of Social Service Agencies and Nurses in Primary Care, (1974). Bass, M.J., Dickie, G.L. Improving Record Keeping Through Self-Audit, (1974). Biehn, J.T. Communication in Referrals, (1976). Blacklock, S. The Symptom of Chest Pain in Family Medicine, (1975). Brennan, M., Jones, R., Spano, L. Patient Profile Card, (1975). Brock, C. Referrals in Family Practice—Expectations and Reasons, (1975). Gall, J. The Symptomatology of “Colds” in Practice, (1975). Hogg, Wm. Emotions Generated by Night Calls, (1975). Jackson, J. Hysterectomy—Sign or Symptom, (1975). McCullough, D., Morrissy, J. Minor Tranquillizer Use and Preventive Care, (1975). McWhinney, I.R., Gibson, G., Molineux, J. Evaluation of a Clinical Clerkship in Family Medical Centres and Community Practices, (1974).

Molineux, J., Hennen, B.K., McWhinney, I.R. The Evaluation of a System for Assessing the Performance of Physicians, (1974).

Morrissy, J. Hematological Values in People Over the Age of 55, (1975). 84/ Prevention in Primary Care

Stewart, M., McWhinney, I.R. The Doctor-Patient Relationship and Its Effect on Outcome, (1975). Wilson, J. Family Utilization of a Medical Centre, (1974).

3. Published Research Bass, M,J. Physician Listing Service Helps Newcomers, Ontario Medical

REVIEW, Vol. 42, No. 1, p. 13, 1975. Bass, M.J. The Pharmacist as a Provider of Primary Care. Canadian Medical

Association Journal, Vol. 112, p. 60, 1975. Bass, M.J. A Profile of Family Practice in London, Ontario. Canadian Family

Physician, Vol. 21, No. 9, p. 1 13, 1975. Bass, M.J. An Ontario Solution to Medically Underserviced Areas. Canadian

Medical Association Journal, Vol. 113, p. 403, 1975. Bass, M.J. Approaches to the Denominator Problem in Primary Care Research.

Journal of Family Practice, April, 1976, p. 193. Bentsen, B.G. The Accuracy of Recording Patient Problems in Family Practice.

Journal of Medical Education, Vol. 51, p. 31 1, 1976. Biehn, J. “Being Taught Upon” The Patient’s View. Canadian Family Physician, March, 1974. Brennan, M. Information Exchange and Retrieval in Family Medicine. Canadian Family Physician, August, 1970. Brennan, M., Jones, R. Gonorrhea in Asymptomatic Females—Epidemic or Not? Canadian Family Physician, Vol. 22, p. 251, March, 1976. Dickie, G.L. Symptomatology of Urinary Tract Infections. Can. Fam. Phys., 1975, Dec. Hennen, B.K., Lamont, C.T. The Use of Simulated Patients in a Certification Examination in Family Medicine, Journal of Medical Education, Vol. 47, No. 10, 1972. McWhinney, I.R. The Family Physician as Research Worker. Canadian Family Physician. 1969. McWhinney, I.R. Beyond Diagnosis: An Approach to the Integration of Be- havioural Screening and Clinical Medicine. New England Journal of Medi- cine 387:384, 1972. McWhinney, I.R., Smith, D. Comparison of the Diagnostic Methods of Family

Physicians and Internists. Journal of Medical Education, Vol. 50, No. 3,

p. 264, 1975. Newell, J.P., Dickie, G.L., Bass, M.J. An Information System for Family Practice, Journal of Family Practice, in press. Spitzer, W.O., Harth, M., Goldsmith, C.M., Norman, G., Dickie, G.L., Bass, M.J., Newell, J.P. The Arthritic Complaint in Primary Care. Journal of

Rheumatology, Vol. 3, No. 1, April, 1976. Stewart, M., McWhinney, I.R., Buck, C. How Illness Presents: A Study of Patient Behaviour. Journal of Family Practice, December, 1975. ments of family medicine to teach, to serve, and

above all, to guide research. That breed is sadly needed. DISCUSSION SMITH: You describe a person who’s going to have his foot in both camps as the appropriate individual to guide us in the collection and use of data,

etc. The question is where such persons might best be educated for this role, and how this education FARLEY: Dr. McWhinney cautioned that we might be funded. Specifically, should this occur in shouldn’t get inundated with data except as it pro- private institutions whose trustees might not be par- vides for some functional practice or research pur- ticularly forward-looking, or at publicly-supported pose. I would like to emphasize the potential medical centers where the State, in assuming respon- research usefulness of data systematically collected sibility for public needs, would be supportive of such and coded in a large number of family practices. Re- a program, or would the education be based in actual cently, Evan Charney, in the Pediatrics Department primary care practices in the community? at Rochester, came to us and wanted to do a trial KISSICK: The distinction between private and of antibiotic prophylaxis of recurrent otitis media. public institutions in higher education is evaporating Within several days, Jack Froom, in Family Medi- at a very rapid pace. I’m on the faculty of a private cine, provided him with coded records from a institution, but we've been told that if the public cork population of 12,000 pediatric patients from which is pulled, we go down the tube. So the decision to select cases and controls. They were able to start process is going to be very similar. the study in a week, compared to the months or years Fd just like to toss out what is one of the most and considerable additional funding that would have fascinating things about the British National Health been required to start de novo. Service, which claims that the family physician is

BERG: To extend beyond the potential for study the backbone of the service. The family physician is of disease management and diagnosis, there’s an de facto the backbone of the service, although the even larger potential for research in the health serv- status and the income goes to the consultant who is ices or health management aspects of primary care. the specialist. But when you examine their budget,

FARLEY: Despite these good feelings and a what they have done and are doing is providing 80 limited amount of demonstrated usefulness of coded percent of their health care with 12 percent of the primary care data for study purposes, our residents budget. have expressed rightly, a need to get people helping One of the things that will really sell family medi- at a high level to use this data. cine, in our society, including the kind of post-

STOKES: This reminds me of the guy in the graduate education being discussed, is cost department of medicine ten years ago who used to effectiveness. It’s a more cost effective way of pro- start a study and collect reams of data and then viding primary care and preventive care, within walk in to some unsuspecting statistican and dump certain limitations, than what we've got presently. the data on his desk and say, “Analyze it.” That was I think politicians have that message. I'm not sure bad news then and it will be bad news all over if the rest of us do. family medicine collects reams of encounter form SCUTCHFIELD: Traditionally, the university data and then hauls it down to preventive medicine health science center, be it private or publicly sup- and puts it on the desk and says, “Analyze it.” ported, has the resources for research to build the This hopefully can be avoided by developing ap- intellectual background that Drs. Stokes and Mc- propriate study design, data management or exper- Whinney have appropriately pointed out. I'm sure tise from within the ranks of family medicine. I am that would be the primary mechanism.

thinking of a breed of individuals who are fully con- Accordingly, I would hope that, if in fact there is versant with family medicine, who go through a some strong commitment to family medicine at the family medicine residency, and then spend at least national and State level, there would be the com- a year, maybe two or three, working in a particular mitment of resources for university-based research discipline such as health services research, and then in just the kinds of things that are being discussed.

come back as full-time academicians in the depart- But I think there’s a further point to be made, and

85 86/Prevention in Primary Care

that is that some of the most fascinating research the university center, it doesn’t preclude the family has been done by a family physician with his record physician from obtaining research capability in his system (e.g., the work of Fry and Pickles in En- residency training so that he will carry it on in his gland). practice.

Since the focus of research is likely to continue at preventive and social-minded of the traditional specialties, feeling relatively comfortable with public

health, e.g., well-baby, school health and crippled

COMMUNITY AND SOCIAL childrens’ programs. It has emphasized normal MEDICINE IN PRIMARY CARE growth and development, nutrition, primary protection against infectious diseases through immunizations, and maternal child-rearing education. Relatively modest fees and total income levels, plus in the health maintenance Leslie A. Falk and boredom and counseling role prompted a precipitous decline in F. Douglas Scutchfield pediatric resident recruitment about a decade ago. The pediatricians then led the traditional specialities in fostering the expanded nurse role, the nurse practitioner, rec- INTRODUCTION ognizing her independent care possibilities but asking that she join the pediatrician in a “team” to provide

This paper first identifies some major streams care to patients (H. Silver et al., 1968). that are important in the consideration of the rela- Family medicine (AAGP, 1968) has recently

tionships between community/social medicine and taken its place as a speciality, the speciality of the primary care. These streams are: ongoing relation- generalist, requiring the same length of residency

ships between community and social medicine and training as medicine and pediatrics (i.e., three

traditional primary care providers, the emergence of years). It has acquired a high consciousness of role the health care team and of the consumer movement and mission. The Society of Teachers of Family in health care. Medicine has identified special viewpoints and skills considered to be uniquely feasible for this speciality; Professional Streams many of these are at the preventive, family, and so- The primary care physician represents “first con- cial levels. Both the Society of Teachers of Family tact” with the patient or the family. The disciplines Medicine and the American Academy of Family currently most thought of as providing primary care Practice demand equal status for family medicine are internal medicine, pediatrics and family medi- with other recognized medical specialties, and want cine. medical school and hospital department status. How- The traditional educational stream of internal ever, they have been tolerant of the rather large num-

medicine is based on in-hospital care as its model. ber of medical school Departments of Family and Although prior antipathy existed between internal Community Health, which handle both subjects, at- medicine and community medicine, many internists tempting to integrate them, especially at the medical

now consider that community medicine is one of its student level. Different tracks are necessary to sub- (or super-) specialties. “Comprehensive care” achieve approval for the respective specialty boards (Falk, 1972) has become an important viewpoint at the residency level. of many internists. These internists adopted (in the Many of the social and humanitarian concerns 1950’s) dimensions of comprehensive care that are (Wolfe and Badgley, 1972) which previously had preventive and rehabilitative in nature as well as led medical students and young graduates into social, curative; they discovered streams of preventive and preventive, and community medicine are now clearly social medicine, and incorporated them into clinical evident in family medicine circles. Family medicine

practice. Among these dimensions are epidemiology, approval bodies require that all persons of the family, home care, medical care organization and health of whatever age, be eligible to come to the family

administration. While this identification is occurring doctor. They stress continuity of care over months in internal medicine, the words in the Internal Medi- and years. A “Model Family Practice Unit—MFPU” cine Specialty Board “Essentials” still do not reflect is required as a teaching base. The family medicine this. faculty emphasizes long term continuity of family Pediatrics (Goldman, 1945) has been the most care. The interdisciplinary care family health team

87 88 /Prevention in Primary Care usually includes the nurse, health workers and some- Then, repeated clarification of roles, differences and times the social worker and dental team, though overlap, is desirable. Leadership functions may shift, these are usually at the secondary level. The two depending on the problem and who knows most major variants are: a private practice with a small about possible answers. Decisionmaking responsi- group of family doctors, or a comprehensive health bilities and processes must be agreed upon. Com- center with family health teams providing extensive munications must be clear, and a matter for consultation and referral personnel and services continuous effort. Evaluation of successes and fail- under the same roof. ures should then lead into a new cycle for changes The resident in family medicine begins to acquire to improve health care. families and patients slowly, but by the third year of Consumer Stream the residency must handle a heavy office load, plus following patients in the hospital under decreased A community (Wolfe, 1971) and a consumer supervision as preparation to enter independent stream have occurred simultaneously (Falk, 1975). practice. Nationally, there is increasing dissatisfaction with Thus, community medicine now has known rela- the U.S. health care delivery and payment system, tively congenial ways of entry into primary care as a portion of what is called the “crisis in health education in the three main specialties of pediatrics, care.” Much of the dissatisfaction stems from the internal medicine and family medicine. New patterns fragmentation of health care. The patient wants and will undoubtedly emerge, e.g., relating to obstetrics needs a person to whom he can relate for the ma- and gynecology. jority of his illnesses, to help him maintain his health, to serve as a health advocate, to guide him through The Health Care Team the superspecialty services, to help put the pieces to-

We should note an important trend in primary gether, and to explain his illness and what is being care delivery. Increasingly, the primary care physi- done about it. The patient wants someone with the cian assumes a participating, coordinating or manag- ability to counsel, to guide in the sresses of daily living role with nonphysician providers of health care. ing. As practice became a series of specialties, most

That is, the primary care physician, in the office, physicians seemed unwilling to make a home call or may be directing the care of patients by a nurse to be on duty nights and weekends. Hospital emer- practitioner, a physician’s assistant, a certified nurse gency rooms became the only resource for many midwife, a family health worker and others. The pro- (Weinerman, 1966). vider may also be coordinating the care the patient At one time even group practices and group receives through referral to other primary care pro- health plans projected values the patients could not viders in the community, such as a public health accept, e.g., “the personal doctor-patient relation- nurse. This trend toward a primary health care team ship is a myth; a good team of specialists can give seems to enable improved quality and comprehen- better quality care” (Weinerman, 1964). But pa- siveness of the care received by the patient and the tients cling to the dwindling supply of “general family. Given this growing fact, it is necessary for us practitioners” as “my doctor.” Fortunately, some to begin to think of the “primary care team” or perceptive and honest thinkers identified this flaw in “family health team” and their education, and to such health care delivery systems and stressed the begin to examine the “core” knowledge that is nec- values of the personal physician and personal nurse, essary to provide primary care, regardless of the dis- and of the importance of continuity of medical care ciplines of the provider. So, the reader must realize (Weinerman, 1968). that while we are discussing the primary care physi- Socially concerned medical students, as well as cian, many of the points that are made here have consumers, became aware of these needs, an aware- applicability to disciplines in addition to medicine, ness which prompted many students to veer from and should be considered in the education of the laboratory research and the ultrascientific sophisti- primary care team, hopefully in an interdisciplinary, cation of the superspecialties back to the primary “same time, same place” manner. Knowledge, atti- concern of the prototypic personal physician, the tudes and skills in patient care and in working to- concern for the patient as a person, family and com- gether really require concurrent education. Mutual munity member. agreement on goals of the team must come first. The consumerism flame then blew white-hot under Community and Social Medicine/89 the wind of the Black Revolution in the United and medical care. There are other areas in com- States (Madison, 1969). Civil disobedience and so- munity and social medicine with relevance to pri- cial struggle swept away publicly legal discrimina- mary care. tion, as the needs of the poor and deprived found a The ensuing discussion will center on broad goal voice. The “Right to Health and to Health Care” statements and some objectives for educational activ- erupted as a demand and a Federal legislative re- ities, and evaluation methods. sponse resulted. The Economic Opportunity Act, as Epidemiology and Biostatistics amended in 1968, enabled development of many dozens of neighborhood health centers. These grew Epidemiology may be defined as the study of into the hundreds as Section 314-E of the Compre- distribution and determinants of disease within a hensive Health Planning Act of 1966 (PL 89-749) population group. We broaden this definition to enabled demonstrations in health delivery and pay- include the determinants and distribution of health ment. Funding of the OEO-sponsored centers was within the population. Epidemiology and biostatis- then unified with that of the 314—E developments, tics form two of the basic sciences for community/ and administered by the Department of Health, Edu- social medicine. Their knowledge is important for cation and Welfare. The comprehensiveness of bene- primary care practitioners. fits has been broad, tending to include medical, In order to define the role of epidemiology in dental, social, nutritional, pharmaceutical, transpor- primary care we should first examine the relatively tation and even legal services. These neighborhood unique position of the primary care physician in health centers, family health care plans and “store- health care and endeavor to see how he can use this front clinics,” involved “maximum feasible partici- position. pation” or “control” by organized lay representatives The primary care physician is responsible for con- of the community in their policy, broad planning, and tinuity of care, and for that reason, he usually has a evaluation. well-defined group of patients who look to him for

As rural areas became increasingly deprived of maintenance of health and treatment of their ill- any physicians (Nolan and Schwartz, 1973) rural nesses. If he assumes this role, there is a clear-cut legislators responding to needs of their constituents delineation of the group he serves. From an epidemi- began to demand that public funds be used to enable ologic point of view, this constitutes a fairly accurate farm boys and girls to become family practitioners, denominator. Because the family and its members hoping to attract them to return to the community receive care or have their care directed by the family from which they came. These legislators began to physician, it is possible for the physician to observe provide resources, and even to mandate the direc- the patient and the family over extended periods tion of medical education of State medical schools. of time (Group Health Insurance of New York, For example, some legislatures have required de- 1963). This allows him to observe the complete partments of family medicine in their State-supported natural history of a disease from the exposure of medical schools. Federal appropriations for family the at-risk patient to the resolution of illness. The practice education increased only a bit later. primary care physician is unique among health pro- With the increasing public demand for improved viders also, in that he has the responsibility for the primary health services and support for education of maintenance of health in his population as well as primary care providers, it seems necessary that the the treatment of its diseases. One of the keystones of academic medical community be responsive to these prevention is epidemiology. Health hazard appraisal developments. One means of support is providing in patient care arises directly from it (Sadusk and the field of family medicine with relevant bodies of Robbins, 1966). knowledge. In developing warm relationships, com- A characteristic of the primary physician is his munity medicine should lead the way. necessary concern with the resources of his community. His patients are obviously influenced by COMMUNITY MEDICINE IN PRIMARY CARE their work and living environments, by their physi- We will deal with only four areas of community/ cal and by their cultural milieu. The health of the pa- biostatistics, tients likewise influences the health of the social medicine; ( 1 ) epidemiology and com- (2) cultural-behavioral sciences, (3) environmental- munity. Thus, community resources may be brought occupational health, and (4) health administration to bear on the patient or his family, either to assist in 90/Prevention in Primary Care maintenance of their health or in remedying their in improving health needs to be appraised. disease. Likewise, these community resources may be (Morris, 1964) inordinately consumed by the over-burdened families The primary care physician must know the range if health maintenance lags. of community health services available to his popula- Given this relatively unique and pivotal responsi- tion and be prepared to use these effectively in his bility, the primary care physician needs accurate own practice; he should know the relative merits of data. Only with effective records and data organi- these prior to assuming a practice responsibility. He zation is it possible for the physician to maximize should be able to evaluate his current organizational his capacity to deal with the patient, family, and the and administrative practice decisions and alter them community. Useful tools for collecting such data in- to meet the needs of his patients and his community. clude the problem-oriented record, special registries He should also be committed to evaluation of his by disease, age and place of residence, plus service performance in providing care to his patients and in and cost reports. How does this relate to epidemi- examining the effectiveness of that care. These efforts ology? will lead to definition of performance deficiencies, Morris (1964) has identified several uses of epi- which will then become the educational objectives demiology, and we have taken those that relate for the family physician’s continuing education. This directly to family medicine as a key for our discus- seems best done in organized local settings such as sion. in hospital medical staffs and in group practices. Peer review methods for quality, utilization and ef- To diagnose the health of the community, and ficiency are extremely important to the practicing the condition of the people, to measure the family physician. present dimensions and distribution of ill-health in terms of incidence, prevalence, and mortal- To search for causes of health and disease by ity; to define health problems for community studying the incidence in different groups, de- action, and their relative importance and pri- fined in terms of their composition, their in- ority; to identify vulnerable groups needing heritance and experience, their behavior and

special protection. Ways of life change, and environment, describe their patterns, and esti- with them so do community health and health mate the relative importance of different causes problems; new indices of health and disease in multiple etiology; to investigate the mode must, therefore, always be sought. (Morris, of operation of the various causes. With knowl- 1964) edge of causes comes the possibility of preventing the incidence of disease. Postulated The patient’s health will be influenced by the com- causes will often be tested in naturally occurring munity, and the community’s health will be affected experiments of opportunity, and sometimes by by the health of the patient. planned experiments of opportunity, and some- The community have resources to bring to must times by planned experiments in removing bear on the diseased patient. The primary physician them. (Morris, 1964) has the capacity and responsibility to develop com- The primary physician can become involved in a munity programs which will assist in the care of the variety of studies of the determinants or distribu- patients. He can also serve a surveillance function to tions of diseases as well as health services. There pinpoint epidemic or endemic diseases in his com- are excellent illustrations of research by primary munity. By maintaining adequate records, he should care physicians with inquiring minds and effective be in the position to recognize correctable community record systems in Britain, Canada and the United health hazards which create illness in his patient States (Wolfe and Badgley, 1972). In our opinion, population. primary care might well concern itself with that

To study the ways health services work, with research which has as its goals improved family a view to their improvement. Health services health maintenance, preventive and self-care effects, research translates knowledge of community improved methods of patient care, improved office health in terms of needs and demand. The sup- functions and procedures, and steadily increasing ply of services is described and how they are levels of primary health team proficiency and ef-

utilized; their success in reaching standards and ficiency. One prototype is that of comparative ef- Community and Social Medicine/91 fectiveness of different primary care systems (Hulka able. If an individual does not perceive a life situ- and Cassel, 1973). ation as an illness, he usually will not consult a member of the health care system (Karl and Cobb,

Culture and Behavioral (Social) Sciences 1966). Even after an illness is perceived, the nature of the

Culture is the “totality of socially transmitted be- person consulted differs within cultures. The poor havior patterns, beliefs, institutions and all other more frequently consult friends, family and folk products of human work and thought characteristics healers first. If further care is necessary, they then of a community or population” (American Heritage seek that professional whom they consider the least Dictionary, 1969). While not unique to community higher class or expensive, for example, a local medicine, we consider behavioral science as a basic pharmacist or a practical nurse, rather than a physi- discipline in the field, especially at the social group cian (Bane, 1963). Minority group health belief level. It provides insight into ( 1 ) attitudes, beliefs, systems may be strikingly different from those of and actions involved in obtaining personal health health care providers. A lack of perception of this care, (2) interactions between family members, and by the physician, nurse and other health personnel (3) the occurrence of disease as related to a culture, will interfere with compliance in professionally e.g., diseases of civilization. The primary physician prescribed regimens. This takes the form of lapsing must “face the real and total problem” of the patient with medication and “not following physicians’ (American Academy of Family Practice, 1965). orders.” It may also take the form of “shopping” for This involves the sociocultural aspects of the pa- health care in different systems or seeking episodic tient as well as the clinical aspects. An awareness of care. Among Latin-Americans the “hot-cold” theory the differences in behavioral patterns, work and must be adhered to. thought processes among different socioeconomic The physician, while treating the patient, cer- groups is important. tainly exerts influence on behavior patterns of the The poor constitute a subculture within the family. The family also influences the care the patient broader United States culture. They have an entirely receives. Family factors which are important to the distinctive set of behavioral patterns. These patterns care of patients include such things as the stability of have positive as well as negative aspects, as they the family unit, the extent of emotional support in enable the poor to survive in society. These patterns time of stress or illness, and the responsibilities and are: (1) orientation to the present, (2) concreteness, perception of the child-rearing process. Thus, the including the hourly struggle for food, clothes, and family physician must know the family environment housing, (3) “authoritarianism” (according to this in undertaking the care of the individual, since he is source), and (4) “fatalism.” These characteristics, also assuming the responsibility for the family, its in addition to lack of income, obviously influence care, and its ability to cope with the illness of one of their pattern of use of the health care system its members. (Young, 1964). The understanding of cultural influences on the

The rural middle class differs in its health-related patterns of disease is another facet of the relationship behavior from the urban middle class. Patterns of of social science to health care. The shift in mortality behavior influence the use of personal health services rates from predominantly infectious to predomi- and the character of that use. nantly chronic disease in the United States occurred Cultures differ in their perception of illness. For earlier in urban than in rural populations. Our cur- example, hookworm disease in the South around the rent way of life has resulted in the emergence of a turn of the century was so prevalent as to not be new set of diseases known as the “diseases of civili- considered an illness, (Pettigrew, 1964). This cul- zation.” They are attributable to shifts in life style, tural difference is also true in the willingness of a including diet, the automobile, changes in the work- population to “assume the sick role.” Cultures differ place and environmental pollution (Esposito, 1970).

in how they handle pregnancy, whether or not it is The role of social disorganization as a precursor to

considered an illness,” and how the pregnant woman a variety of diseases is becoming increasingly ap- responds to labor. Perception of illness and assump- parent (Cassel, 1974). tion of the sick role relate to the seeking of medical In order to maximize his potential to affect the

care, providing it is financially and physically avail- health status of his patients, families, and commu- 92/Prevention in Primary Care nity, the primary physician needs a working knowl- Resources available from health and labor de- edge of these sociocultural influences on health partments should be familiar to primary care practi- and illness. A reservoir of knowledge in these areas tioners. What is OSHA (The Occupational Safety

(as well as other bodies of knowledge of relevance and Health Act of 1970)? What does it require of all

to the physician) lies in the department of community . . employers in protecting their employees . one’s medicine. It seems imperative that the student in patients? What is the Workman’s Compensation Law the undergraduate curriculum, as well as the physi- in one’s State? Does it allow a primary care physician cian in postgraduate training, be made aware of to see his patient when industrially sick and injured, these issues and their relevance to primary care or does it require the patient to see a “company doc- practice. tor”? What are “Black Lung Benefits”? What are Medical sociology, social psychology, medical an- specific Social Security benefits? Does the primary thropology and other aspects of the social and be- care physician know about and refer to the voca- havioral sciences are now considered part of a core tional rehabilitation service or to other special serv- student curriculum and of the family practice resi- ices (for the blind, deaf, epileptic) to habilitate or dency. We urge the scientists and teachers of the be- rehabilitate? havioral sciences to work more often in primary care Each technical advance has tended to produce its settings,, so they are able to base their pedagogy on own occupational and environmental problems. Phy- relevant experiences. sicians using X-ray were an early example (Codman, 1902). Fifty years ago, radioactivity appeared as a Environmental and Occupational Health killer of fluorescent wristwatch workers who were Major types of environments include: work, home, painting luminous dials (Martland, 1929). Other community, physical, and sociocultural. Accidents forms of radiation exposures became a prototype of within the home, on the roads, and at work are the interrelationship between the work and the com- major causes of mortality and disability for a large munity environment. Even substances used for many portion in our younger age groups (Falk, 1974). The years have not been adequately tamed, e.g., asbestos primary physician must assume the responsibility and lead, the former now a malignant giant. for attempting along with the family, labor, manage- Occupational medicine stresses the preventive and ment and public officials to develop preventive educational as well as the compulsory and the legal. measures to reduce accidents. Health examinations and health counseling are at the He must be able to recognize work-related heart of the best industrial medical departments’ diseases, which he is likely to see in practice, yet activities. Physicians, nurses, and industrial hygien- often misses due to lack of awareness of the problem. ists are often the core industrial health team. Safety He should assume an active role in working with engineering is a key aspect of accident prevention. industry to prevent these occupationally related ill- Psychological testing, counseling and industrial psy- nesses. chiatry should be understood, including their biases. Occupational medicine attempts to maintain the All these, once again, must start with the medical, health of the worker, to prevent disease when pos- nursing, and other health students and housestaffs. sible, and to cure it promptly when it is not pre- The environment of almost the entire United States vented. It attempts to rehabilitate through a focus population is now threatened by the industrial wastes on recovery of function when lost. Health counseling and personal machines (e.g., autos) which pollute and health maintenance are today’s goals in occupa- our air, water, food and drink. Occupational medi- tional health. cine now inevitably combines with environmental

Taking a good occupational history is a basic skill medicine. Whether it be at the work place or in the needed in primary care. What specifically does the neighborhood environment, the hazards are syner- worker do in his or her work, and what were pre- gistic. vious exposures? This requires some knowledge of Air pollution, noise pollution, water and soil pol- toxic substances commonly encountered in the work lution—all the aspects of the living environment environment (dusts, chlorine compounds, etc.), which had been thought to be improved or improv- health hazards from excessive noise, accident hazards ing are now threatened or already polluted. Ecology due to exposed machinery. Visiting the place of work as a discipline and viewpoint of the whole and the to observe likely work hazards is invaluable. interdependence of all, should be viewed as a base Community and Social Medicine/93 discipline the primary care physician attempts to medically indigent systems, the Veterans Admin- understand. istration health care program, special eligibles such

The primary physician is in a unique position to as Indians (native American), and the Armed Forces recognize the health consequences of environmental members and their families. pollution and poor sanitation in his community. He Understanding the interrelation between organiza- should assume an advocacy role within the commu- tion and the financing of health care delivery and nity to correct those conditions which produce illness their disparateness is necessary. There must be fa- in his patients and attempt to prevent future illness. miliarity on a day-to-day level with health planning This advocacy role requires an understanding of the and its relationship to organizations in Comprehen- political-social process, and how to alter this process sive Health Planning and Regional Medical Pro- for change. grams within the health care system, such as a hospital or a neighborhood health center. Health Administration and Medical Care Part-time and field health administrators are particularly valuable as faculty members to provide Health administration and medical care are two information to medical students and residents on phrases for a sphere of activity without an accepted those subjects. Health services research personnel short title. Health care delivery, health care organi- can also provide relevant information about these zation, health planning, and community health serv- areas. Both can be drawn into faculty development ices are either components of these phrases or used activities at the residency level. Residents can be as- synonymously with them. Health services research signed to planning, developing and evaluating a is the key investigative field of this core subject. health care delivery system as part of their core time. Cognitive knowledge in these fields draws heavily CONCLUSION from the disciplines of administration, economics, communications, political science, social welfare, The primary care physician, whether internist, history and ethics, among others. pediatrician, or family practitioner, is in a- unique The primary care physician needs to acquire some position to improve the health status of his patients, himself. of the skills of the health administrator families, and the community in which he works if he Examples of such skills include: How to organize has the skills, the attitudes, the appropriate health and run an office and/or complex health care de- care team, and community system. Medical educa- livery service, e.g., understanding laws applying to tion needs to provide learning opportunities to de- affairs; or employees, personnel practices and fiscal velop such physicians. Society is demanding this planning and evaluating the services. Complex health loudly and clearly. care delivery systems such as hospitals, university health science centers, large group practices, nursing homes, comprehensive health centers and health departments are almost certainly to be within the re- REFERENCES sponsibilities of many primary care physicians. The basic methods of financing of health care and the advantages and disadvantages of each must be known. This involves understanding health insur- American Association of General Practitioners (AAGP) ance—social insurance, such as Medicare; private Essentials for residency training in family practice. Re- nonprofit, such as Blue Cross-Blue Shield; and print No 132B, 2 pp. as approved by the House of Dele- commercial insurance, or a country’s National Health gates of the AMA at its Clinical Convention in December Service. 1968.

Familiarity with standards for quality, comprehen- American Academy of General Family Practice 1968. accessibility and sive care, efficacy, efficiency, how The core content of family medicine. A report of the (Pro- they are applied must be understood. PSRO’s Committee on Requirements for Certification. fessional Standards Review Organizations) represent This work was supported by the Robert Wood Johnson a major case in point in the contemporary American Foundation, Carnegie Foundation, and Department of medical practice. There must also be familiarity with Health, Education and Welfare Health Manpower training public medical services such as Medicaid, county grants. 94/Prevention in Primary Care

American Heritage Dictionary of the English Language Morris, JN 1964. Uses of epidemiology. Edinburgh and 1969. American Heritage Publishing Co., Inc. , London, E & S Livingston Ltd.

Anthropological and Ethnological Sciences, Sept 4, 1973. Nolan, RL and J Schwartz (eds) 1973. Rural and Appa-

lachian health. Springfield, Illinois, Charles C Thomas, Bane, BJ 1963. Anthropological perspectives and public pp 159-964. health. The Annals of the Amer Acad of Pol and Soc Sc

346:34-43. Pettigrew, TF 1964. A profile of the Negro American. Princeton, New Jersey, D Van Nostrand Co, Inc. Chaps Cassel, J 1974. An epidemiological perspective of psycho- 1 and 8. social factors in disease etiology. Amer J Publ HIth 64:

1040-1043. Sadusk, JF and LC Robbins 1966. Proposal for health

hazard appraisal in comprehensive health care. JAMA Codman, EA 1902. A study of the cases of accidental 203:1108-1112. X-ray burns hitherto recorded. Phila Med J, pp 438-499. Silver, HK, LC Ford and LR Day 1968. The pediatric Esposito, JC 1970. Vanishing air. The Ralph Nader study nurse practitioner program. JAMA 104:298-302. group. Report on air pollution. New York, Grossman

Publishers, pp 26 and 29. Weinerman, ER 1964. Patients’ perception of group medical care. AJPH 54:88-889. Falk, LA. 1976. History of the consumer in health care

delivery. In Consumer Participation in Health Care. Wolfe, S and R Badgley 1972. The family doctor. New Washington, DC, Government Printing Office. York, Milbank Memorial Fund 50:166,181.

Wolfe, S 1971. Consumerism and health care. Pub Adm Falk, LA 1972. Changing concepts in comprehensive Rev 31:530-531. health care: Comprehensive care in health programs. J of Young, 1964. be Equal. York, the Natl Med Assoc 64(6) : 471-75. WM To New McGraw-

Hill Book Co, chaps 6 and 7. Falk, LA 1976. History of industrial and occupational medicine. Dictionary of American History. New York, OTHER SOURCES Chas Scribner’s Sons. Brown, Frank, 1912-1943 (7 Vols.) Chapel Hill, Falk, LA and I Hawkins 1975. Serve the people: What N.C., Duke University Publishers, p. 354, num-

it would mean for health care in the USA. In Topics and bers 2743 and 2744, for hookworm cure. These Utopias in Health. SR Ingman and AE Thamos (eds) volumes were collected in collaboration with the Chicago, Mouton & Akline Press, pp 413-22. North Carolina Folklore Society of which Brown was secretary-treasurer. Wayland Hand edited the Goldman, Franz 1945. Public medical care: Principles health and illness volume. and problems. New York, Columbia U Press, p 53. Chilman, Catherine, Growing Up Poor. United States Group Health Insurance of New York 1963. Health care Department of Health, Education and Welfare;

issues of the 1960’s. Records of a national symposium Welfare Administration, Washington, D.C., May

conducted Oct 2, 3, 4, 1961 as a public interest activity 1966. of GHI. Dixon, J. P., The Community Responsibility for Medical Care. Medical Care in Transition, 1:81; Hulka, Barbara S and JC Cassel 1973. The AAFP-UNC Reprints from American Journal of Public Health, study of the organization, utilization and assessment of P. 76-81, Vol. 49, Jan. 1959. primary care. JAMA 63:494—501. Donabedian, A. and Axelrod, S. J., Organizing medi- Karl, Stanislav V and S Cobb 1966. Health behavior, cal care programs to meet health needs. Annals of

illness behavior, and sick role behavior. Arch Env Hlth the American Academy of Political and Soc. Sci- 12:246-266. ence; 337:46. Farley, E. S., Jr., Suggestions for the Content of Madison, DL 1969. Organized health care and the poor. Training of the Family Practitioner in the Under- Med Care 26:783-807. graduate Curriculum. Unpublished memorandum.

Martland, HS 1929. Occupational poisoning in manufac- Irelan, Lola M., Low Income Life Styles, United ture of luminous watch dials. JAMA 92:466, 552. States Department of Health, Education and Wei- Community and Social Medicine/95

fare; Welfare Administration, Washington, D.C., 1966. Health is a Community Affair, Cambridge, 1966. Massachusetts. Harvard University Press, Chap-

Koos, L. K., The Health of Regionville: What the ters 1,17, 53. This report is a significant appraisal

People Thought and Did About It, New York, of the personal and environmental health services Columbia University Press, Chapter 6. needed, with authoritative recommendations for National Commission on Community Health Service, action. sponsible for the declining numbers of primary care physicians who are necessary to care for the 241 patients who consulted a physician but were not DISCUSSION INVITED admitted to the hospital. This awareness prompted many departments of community medicine to launch primary health care programs, such as the neighborhood health centers. These concerns of community

F. Douglas Scutchfield medicine also allowed it to be strongly supportive of and to participate in the development of the family medicine educational experiences within medical schools. Perhaps community medicine’s outspoken Prior to making any formal remarks about the supportive role of family medicine prompted our manuscript prepared by Dr. Falk and myself, I would colleagues within the medical center to identify like to comment on a trend which is relevant to family medicine as a “portion” of community medi- primary care education. In my discussion I assume cine. Family Medicine is the leading speciality involved I personally believe that this trend identified by in primary care, but recognize that other specialities our medical education colleagues is not, in the long have and desire a role in primary care. run, productive either for family medicine or com- This trend is to combine departments of family munity medicine. Each discipline should be recog- and community medicine. We must recognize that nized as a distinct entity within the sphere of medical family and community medicine are two separate and education and these two disciplines should jointly distinct disciplines. The focus of community medi- demonstrate the relevancy, priority and necessity for cine is the community, an aggregate of individuals primary care delivery in an organized context. I am and families; the focus of family medicine is the not absolutely opposed to joint departments of com- family and its members. The base sciences of community and family medicine. In those institutions munity medicine include epidemiology, biostatistics, with a strong community medicine department, it behavioral science, operations research and econom- well might serve both community medicine and fam- ics. These are all disciplines which deal with at- ily medicine to allow the departments of community tempts to explain and modify group behavior. The medicine to “incubate” family medicine, but we base sciences of family medicine are clinical in should, as soon as possible, spinoff this department nature, pediatrics, internal medicine, psychiatry and to assume its place on an equal footing among other the like. These focus on the individual patient, not departments of the medical school. on the aggregate. The family, the unit of family It is appropriate for us to not lose the opportunity medicine, represents a good meeting ground for to work with the other clinical departments in our those two disciplines, and the comments in our rush to implement and support the family practice manuscript illustrate common concerns and relevant movement. We must recognize that one of the major information that community medicine has for pri- responsibilities of the department of community mary care education. medicine is to create, develop and evaluate com- As practitioners and researchers of community munity health programs. These programs will not medicine, we are aware of and supportive of the only be used by family physicians, but also by other need for effective primary care. Primary care repre- primary care specialists, as well as secondary and sents the “crunch” in health care as illustrated in tertiary care physicians. the paradigm generated by Kerr White in Ecology It seems reasonable to suggest that because of their of Medical Care (1961). In this paradigm White concurrent goals, comprehensive and continuing points out that of 1,000 patients during a month, care, family medicine and community medicine can 750 will report an illness, 250 seek physician care work effectively as two separate departments to ob- and only 9 are admitted to the hospital. While this tain a voice in policy decisions in medical schools. is true, our medicine educational system currently Both departments currently have little input into focuses on the 9 hospital patients and attempts to policymaking. Perhaps two departments would have produce individuals exquisitely trained to provide a greater voice than one department with two units. this care. This educational emphasis is in part re- The departments must work together in order to

96 Community and Social Medicine/91 obtain those trappings of influence which are appro- community diagnosis, as originally described by priate in medical education circles. These areas in- McGavran (1956). They view community health clude: 1) Inpatient beds in university hospitals. problems as a physician views individual health prob- Family medicine should not be looked upon as lems. Therefore, we ask the student to take a history second-class medicine which can only be practiced and obtain chief complaints from various people in the community hospital. 2) Curriculum time. within the community and have them identify the Community medicine has been traditionally short in community’s health problems. The student examines terms of curriculum time. The same thing is now objective data to confirm or deny the impressions happening to our family practice colleagues. 3) Ap- he has received from the history. He then formulates pointments to policymaking committees. The two a problem list composed, in priority rank, of those departments should work together to obtain appoint- community health problems which he has identified. ments to policymaking committees, such as the Some of the problem lists generated by this process curriculum committee, the promotions, appoint- appear elsewhere (Scutchfield, 1974). We anticipate ments, and tenure committee, and the like. 4) Fi- that the use of this knowledge in the community nancial resources. Possibly the most important source will seem self-evident to the student, and anticipate of power and influence in the medical education that when the student enters practice, he will do a community has to do with getting resources for community diagnosis of the community in which he faculty and residents’ salaries. These resources allow chooses to practice. From this we hope that he will for the growth of an adequately-sized department serve as a leader in developing programs to speak to assume responsibility for this valuable portion of to the problems he has identified in his community. the medical education program. We have spoken briefly about the identification of

Recognizing that there is a difference between high risk cohorts of patients in the family physician's family medicine and community medicine, what is practice as a mechanism for preventing and resolv- common ground between the two disciplines? Our ing those problems. Identifying these cohorts involves manuscript identifies some of these, such as epi- a knowledge of epidemiology and the practical demiology, biostatistics, sociocultural knowledge and use of office records as an epidemiological tool. health care organization. The overlaps can be further We also feel that community medicine can make defined through the mechanism of behavioral ob- important contributions to practice management by jectives. The University of Washington Department the family physician. By using the epidemiological of Family Medicine has identified “Competency- and biostatistical tools which community medicine

Based Objectives for the Family Physician” (Baker, has available, it would be possible for the family

et al., 1974). We in community medicine should physician to evaluate his practice for efficiency, ef- likewise identify the competency-based objectives of fectiveness, and quality. We know that the physician community medicine. Where overlap exists between in the community will assume leadership roles by

these two sets of behavioral objectives, there is an his position on county boards of health, medical obvious field for common education of undergrad- staffs, comprehensive health planning councils, and uate students and residents. other advisory and policymaking groups. In work- Another important contribution that we in coming with physicians in the community to develop

munity medicine can make to family medicine is the community health programs, the University of Ken- use of community diagnosis. All physicians, regard- tucky graduate has been extremely easy for us to less of speciality or location, practice in a commu- work with, as he has a grasp of the needs of his

nity. This occurs whether an individual is a neuro- community. We hope that the broad aggregate of surgeon in downtown Manhattan, or a family disciplines in community medicine will allow him to physician in Wolfe County, Kentucky. At the Uni- effectively serve in this capacity in the community. versity of Kentucky every undergraduate medical Let me conclude by making one additional com-

student learns how to do a community diagnosis. ment. The patient in community medicine is the

We require all students during their junior year of community, and the patient in family medicine is medical school to spend five weeks in one of the the family. Just as in family medicine we would not fifteen governmental planning regions in the State think of teaching the precepts of family medicine of Kentucky. They work in groups of five with a without having a family to practice on, so we should faculty preceptor. During this time, students do a not think of teaching community medicine without 98 /Prevention in Primary Care having a community to practice on. We in the De- partment of Community Medicine have a responsi- REFERENCES bility to take a proactive role in working with communities to identify the community health problems and to assist them in the development of solutions Baker, RM and MJ Gordon 1974. Competency-based to those problems. When we assume this responsi- objectives for the Family Physician. Asso for Hosp Med bility we will see two things: recognition from our Ed 2-16. students and fellow faculty members, and the valu- 7(2): able contribution we have to make to primary care McGavran, EG 1956. Scientific diagnosis and treatment education. of community as patient. JAMA 162:723-727.

Scutchfield, FD 1975. Alternate methods for health pri-

ority assessment. J. Community Health E29-38.

White, KL, TF Williams, BG Greenberg 1961. The ecol-

ogy of medical care. New Eng J of Med 265:885-892. munity medicine was going to be medicine delivered in the community. What did we do? We got the money and developed DISCUSSION a neighborhood health center, the format of which was to provide family health care with family health teams. That subsequently became the basis for our family medicine program. Now, five years later, we

are spinning it off into the community. We have STOKES: If the departments of preventive, com- decided that we’re not going to operate a health munity, social medicine are not going to directly service forever, but we did have to operate it for a provide primary care service, as you suggest, what short time. You see, there are so many ways of indeed are they going to do in terms of service? doing this. I’m not talking about teaching or research; I’m CHRISTIAN: Dr. Scutchfield is saying to a talking about services for which one feels responsible family practitioner, “We’ll organize you, and we’ll either to an individual or collective group of patients. plan you, and we’ll set up and supervise you.” For SCUTCHFIELD: The continuing service respon- any community health service to be effective, all the sibility of the community-social-preventive medicine elements have to be concerned with the planning, professor is to deal with communities. Let’s say I including the family physician. He has to be at the went into a community, as I have in the past, in top, helping to plan the service in which he is going rural Appalachia, and the most pressing obvious need to work. Somebody can’t just come in, plan a service was personal health service. Rather than assuming system, and spin it off to him. direct responsibility for health services, departments SCUTCHFIELD: That’s a misunderstanding. If of preventive/community medicine can help the I gave that impression I apologize. All provider, as community develop an organization which identifies well as consumer components, should be involved in health service needs, and gives alternative approaches the initial planning, but the departments of com- to these needs (e.g., family practitioner, nurse prac- munity medicine should have the primary responsi- titioner, multispecialty, etc. models). They can also bility for working with the community because they help in obtaining necessary funds to implement the are the most informed about health administration model selected. and health care organization.

If family medicine is the best clinical department The primary responsibility then is patient care. to deliver primary care, and if the family physician Now, you obviously need to be involved in planning fits into the primary care team, obviously this is those services which will be directly related to the department most closely associated with com- patient care. munities in developing health services. HENDERSON: Listening to the discussion, I’m

ABRAMS: What you are doing is laying down a struck by certain similarities between communities blueprint: No, we don’t give direct health service and patients. We have to remember that one of the but we do it this way, No, we shouldn’t combine important things about serving the needs of patients departments but separate them for reasons which is getting the patients to come to see us in the first you justified. On the other hand, the rest of your place. Likewise, one of the important things about

argument justified keeping them together. It is un- dealing with communities is getting the community productive to delimit our discussion to such adminis- to come to see you.

trative dictates. Our basic purpose is the bringing of One of the commonest health problems presented

preventive/community medicine to primary care. by a community in this day and age is a perceived There are many approaches to this—what’s true in need for family doctors. Maybe this is a correct Kentucky may not be true in Arizona. To illustrate identification of the problem, maybe not, but like a

—when I joined the University of Arizona, it was a complaint which brings the patient to the physician,

department of community medicine, and family it may not be near the entire picture of the problem.

practice was a little bit distant at that point. My It is here that combined resources of community and

first job was to get money from the Federal Govern- family medicine departments must be brought to ment to develop a neighborhood health center. Com- bear to arrive at a solution.

99 100/Prevention in Primary Care

ABRAMS: I’m glad you mentioned it because involved in the diagnostic and the therapeutic proc- we’re in that very situation now. Communities are esses. Thus, we are talking about a kind of research coming to us. How are we meeting their needs or study process which by its nature should bring through the family practice program? about needed change. And by its nature the process WALKER: This discussion has brought out a will be dependent upon close working relations be- very important point about the way community tween community representatives, community medi- medicine departments can successfully serve com- cine consultants, and primary care providers. The munity needs. The term “community diagnosis” im- important role of the community itself initiating plies a professional service in response to an the process, through expression of need, and being expressed need. That need may be for primary care actively involved in the analysis and solution, should practitioners, and if so, they must inevitably be not be forgotten. DELIVERY SYSTEM ASPECTS

The final section addresses the broad issue of the milieu of primary health services of the future—organizational, managerial and, most critically, financial models. While not restricted to the matter of preventive/community aspects of primary care, this question of future milieu is perforce directly relevant to the implementation of all which is presented in the preceding sections. Dr. Gibson reviews three movements which have arisen during the past decade to challenge the failure of the Flexnerian hospital to educate and motivate an adequate number of primary care physicians: Family Practice, Community Medicine and Health Maintenance Or-

ganizations. The paper asserts that as primary care grows it will become increasingly organized into rational delivery models, and there will in turn be a pressing need for a new type of health service administrator; the special attributes required of such administrators are detailed. In

the invited discussion, Dr. Kissick first examines the depth and/or direction of analyses of certain points presented in Dr. Gibson’s paper. Specifically he focuses upon the future usefulness of the concepts of Family Medicine and Community Medicine that are presented and the question of what are or will be the major forces which reshape our health care system. He agrees with the need for a new type of primary care administrator or manager, and briefly describes training programs for such persons at the University of Pennsylvania. General discussion considers, respectively the roles of medical education, consumerism and financing mechanisms, public and private, in changing the health services delivery system.

101 I 6 Most primary care is still delivered in physicians’ private offices. Of 567 million patient visits for pri- FUTURE ORGANIZATION AND mary care estimated for 1969 in the United States, MANAGEMENT OF PRIMARY the percentage distribution was as follows (Parker, HEALTH CARE 1973): Private practitioners 77.9 Outpatient Departments 10.7 Emergency Rooms 7.1 Count D. Gibson Prepaid Group Practices 3.7 Neighborhood Health Centers 0.4 Free Clinics 0.2

Introduction 100.0

It should be noted that the first three institutions For this paper, primary health care is defined as are well established and that the last three have each an organized delivery system that accepts responsi- represented recent efforts to respond to society's bility to care for all the residents of a defined needs—either to control costs, elevate the quality community who wish to use its services. This system of care, make it more comprehensive, or reduce the attempts to protect and increase the health of its barriers to utilization. clients, identify presymptomatic problems, diagnose During the past decade, two movements in med- and treat those diseases within its competence, refer ical schools have sprung up independently to respond patients to more specialized services when required, to the neglected needs for primary care in our so- receive back those who have been referred, help ciety family practice and community medicine. hasten recovery, retard disability, and comfort the — Although there is a high degree of overlap in their dying. Ideally, the system studies the relationship goals, they have so far tended to treat each other of its constituents to the physical, emotional, and warily. In any discussion of the organization and social environment in which they live and the degree management of an ideal primary health care system, to which relationships with their community, em- the history and needs of each movement must be ployer, family, and peers affect their health. considered. The physician is the central figure in this insti- The family practice movement has tended to be tution. This discussion will focus on research and a movement from outside pushing into the medical physician education in primary care and not deal school and teaching hospital. The initiators have specifically with other health professionals—nurses, been practicing family physicians, nonmedical edu- dentists, podiatrists, pharmacists, social workers, et cators like John Millis, and legislators. Important al., who also play crucial roles in primary health goals have included acceptance of the family care. physician as a peer of other specialists and his ac- PAST AND PRESENT PRIMARY cess to the hospital for roles often automatically CARE TRENDS denied to him in the past, regardless of his capa- bilities. For residency training, most model family The discipline of primary health care has only practice units have been based in the outpatient recently received organized attention in American clinic of a hospital. The tertiary care nature of many

medical school curricula and this is surely reflected university hospitals and the hostility of some faculty in the grave shortage of primary care physicians in members in departments of medicine and pediatrics

our society. In consequence fragments of primary have often made it necessary to base the family health care are delivered by a wide and uncoordi- practice training program in a community hospital. nated group including general practitioners, most As long as the formula “academic equals tertiary

pediatricians, some internists and other medical care” persists, however, it continues to retard the specialists, osteopaths, pharmacists, public health acceptance of family medicine as a university nurses, chiropractors, and lay healers. discipline.

103 104/Prevention in Primary Care

A different flavor has surrounded the growth of not been highly valued and the care has not been departments of community medicine. Leaders of organized in a family-centered framework. Just as this movement have tended to move from disciplines the HMO has been little involved in the family med- in preventive medicine and the established clinical icine movement, it has also not been closely iden- departments out into the community. Their activities tified with academic community medicine. The have been closely related to the civil rights move- subscribers to an HMO have been typically re- ment, urban and rural underserved communities, cruited through the company in which the bread- and the Office of Economic Opportunity, and their winner works and not through the community in institutional bases have included Neighborhood which the family lives. Thus, the subscribers to the Health Centers, free clinics, and the like. They have plan are scattered throughout a metropolitan area tended to reject hospitals as a central focus for health and represent a minority of families up and down care and to emphasize a more egalitarian role of their block. The Kaiser Health Plan considers that other health care personnel vis-a-vis physicians. its market is close to saturation if 20 percent of Other characterizations have included studies of the families in a community are subscribers. Thus, at- effect of environment (pollution, housing, nutri- tention to the physical and social environment of tion) on health, the sponsorship of new health families has not been high in the priority of HMO careers such as family health workers, the reduction goals. of barriers to access, and finally the active accept- It is perhaps useful to recapitulate my analysis at ance of a consumer voice in health care. this point. Three groups in the past ten to twenty Both of these movements are now encountering a years have attempted to respond to society’s needs new set of organizational and economic forces unfor primary health care. The Family Practice move- der the label of Health Maintenance Organization ment has focused on the recruitment, formation and (HMO). The fee-for-service system, under which status of the family physician. Its target has been clinical practice has traditionally flourished, has come the care of persons in a family context. It has not under increasing attack as the Federal Government given a great deal of attention to health care eco- (which now already pays for more than 25 percent nomics or to barriers to access. The Community

of all personal health care) realizes that it contains Medicine movement has been characterized by the no incentive for cost containment. In turn, as Fed- development of neighborhood institutions caring for eral bloc grants for Neighborhood Health Centers people in a community context with an emphasis begin to shrink and free clinics feel the need to be- on the health care team, consumer involvement, and come more stable and consistent, the evolution of the integration of clinical medicine and public these centers into health maintenance organizations health. The HMO movement has stressed compre-

is becoming a necessary process for survival. hensive organization of care, efficient planning, Thus, familiarity with the health maintenance quality of individual services and financial self-

organization movement becomes essential for the sufficiency. It has not been notable for a family or educator in family medicine and community medi- community focus. cine. The HMO movement under the traditional label of prepaid group practice has developed as FUTURE ORGANIZATION OF an urban middle-class phenomenon closely related PRIMARY CARE to large industries and trade unions. The pioneering

physicians of Kaiser-Permanente and the Group From the foregoing considerations it now becomes Health Cooperative of Puget Sound received virtu- possible to conceptualize the organization of primary ally no help or attention from medical educators care in the United States over the next twenty-five and were often bitterly opposed by family practi- years. Rather than distinguishing between require- tioners through the medium of organized medicine. ments and desiderata, I will list the elements of a Primary medical care in HMO’s, at least on the model system for which local compromises will West Coast until recently, has been rendered chiefly inevitably be made. by internists and pediatricians. Stress has been 1. Primary care is organized as a nonprofit placed on making available a specified set of serv- corporation, not merely a doctor’s office or profes- ices to respond to episodes of illness. Continuity sional corporation. It cannot meet its goals as a pro- between an individual physician and a patient has prietary branch of an investor-owned scheme. It Future Organization and Management /1 05 cannot reach fulfillment as a satellite function of a health care system to verify if they have health care hospital. needs or desires not currently met. Of course the

2. It is physically located in the community it right of these people to be left alone is essential. serves. Only thus can it share all the ecologic forces Community centeredness also means programs in to which its constituency is subject and in which it health education, coordination with other institu- must develop its priority of goals. For convenience tions such as schools, churches, service clubs, and

I shall refer to the primary care organization as a organizations of employers and employees. community health center. 7. The consumers have an organized and effec-

3. It serves a minimum of 3,000 and a maximum tive input into the programs and policies of the cen- of 50,000 people. The smaller figure represents a ter. This important topic is the subject of another marginal level that can barely achieve certain cru- Fogarty Center monograph (Smith, 1976). cial economies of scale; it is most applicable to a 8. There is a comprehensive and stable system rural area. The larger number is the limit beyond for financing which enhances productivity of the which bureaucracy and depersonalization begin to staff and cost containment of the program compati- grow rapidly. Larger populations are better served ble with a high quality of care. by multiple dispersed health centers remaining close The administration of a primary health care cen- to their communities. ter is a task as new as the centers themselves. So

4. There are clear-cut efficient and effective pat- far, there has been little development of the curricula terns for inpatient care and specialty consultation. needed to educate primary health care administra-

The relationship between the health center and the tors. For the purposes of this discussion, I am assum- hospital is a complex one beyond the scope of this ing a community health center governed by a board discussion. The health center must be able to con- of consumers. In the smaller center, serving a popu- trol the costs and services of the hospital so that the lation of 3,000-6,000 people and having two to four patient will not be subjected to excessive or inap- physicians on its staff, the administration is ade- propriate procedures. On the other hand, concern quately served by an M.D. clinical director and a with cost containment must not interfere with a business manager. In a center at the large end of high quality of care to be rendered. the scale, serving 30,000 people, a full-time senior

5. The care in the center is rendered by family administrator, presiding together with a clinical di- health care teams. Such teams have so far been ir- rector over a more elaborate administrative struc- regularly successful. The more traditional model has ture, is needed. Qualifications of a physician or been the physician as a purveyor of services sur- other professional for such roles would depend more rounded by helpers under his direction. As health on personality, commitment and managerial experi- manpower organization becomes more sophisticated ence than on clinical training. At this point, few

I believe the physician will become the senior mem- medical schools or programs in health and hospital ber of the team and will relate to other members administration are producing personnel with ap- such as middle level medical workers (nurse prac- propriate primary care orientation. titioner and physician associate) and family health Regardless of professional background, the ad- workers. Where appropriate, the team renders its ministrator of the primary care center must have the care in a family-centered way so that advice and following attributes: therapeutic programs recommended by team mem- 1. A knowledge of the culture of the community bers will not be contradictory or conflicting for served. This includes fluency in the predominant or members of a family. Development of therapy important secondary language of the community. It is should take into account the strengths and weak- clearly advantageous to reside in the community. nesses of a family structure. However, this dimen- 2. A grasp of community dynamics and experi- sion must be delicately balanced with the right of an ence with a consumer board. This includes an ability individual to privacy and confidentiality. Team to help the board grow in knowledge and skill, to members can share information and plan joint present issues to the board or to explain clearly why therapy only to the extent that their patients indi- he does not. vidually desire it. 3. A freedom to circulate (Mondragon, 1974).

6. The care is community-centered. This means The administrator must never be so overwhelmed

that attention is paid to those who are not in the that he is pinned to his office all day. A close famil- 106/ Prevention in Primary Care iarity first with all the functions of the health center, CONCLUSION and second with the community is essential to spot changes, identify problems, and develop friendly In summary, the primary health center is seen as links with staff and patient. the keystone to the entire health care system. It must 4. Insight and sympathy for staff undergoing role be responsive to the community, to the family, and strain. Most professionals have not yet been properly to the person. To accomplish these goals, new roles educated for the roles they assume in a community and new ways of doing familiar tasks must be de- health center. Problems of status, “turf” and eco- veloped. The critical figure in this new institution nomic reward often become acute unless identified will be the administrator—a person of many parts. and resolved early. He or she must maintain a delicate balance between, 5. A knowledge of labor relations. Contemporary on the one hand, the human needs and the emotional organizations tend to define and organize power ex- climate of the health center for staff and patients plicitly. Health center administrators should be more alike, and on the other hand, the technical require- prepared than hospital administrators have been for ments for high quality services at the lowest cost. In the advent of trade unionism. fine, the primary care administrator becomes the

6. Familiarity with data processing techniques. linchpin of the new system. The large amounts of data needed to provide information on the operation and effectiveness of the community health center are essential.

7. Ability to develop objectives and evaluate progress in meeting these objectives. This is a complex management process which must involve the REFERENCES entire staff and representative consumers in the development of a plan submitted for approval by the governing board. It has become increasingly impor- American Hospital Association House of Delegates. Febru- tant to make the objectives of a health center explicit ary 1973. and realistic. It can become so all-consuming a

process however, that it can interfere with seeing Mondragon, FE 1974. Public accountability and human

sick people. Once a plan is developed, evaluation of services orientation in health administration. Paper pre-

its implementation is critical if it is to be more than sented to the Institute on New Approaches to Education rhetoric. Inexpensive and efficacious methods for this for Health Administration, New Orleans, Louisiana, Janu- evaluation are yet to be developed. ary 9-11, 1974.

8. Leadership in the organization of an effective Parker, AW 1973. The dimensions of primary care: patient advocate system. The American Hospital Blueprints for change. Paper presented to the Sun Valley Association (1973) has recently proposed a model Forum on National Health, Sun Valley, Idaho, August “Patients Bill of Rights.” While this was an impor- 1973. tant advance it is only an empty public relations gesture unless steps are taken by the administrator to Smith, Keith (ed.) 1976. Consumer Participation in insure that patients understand their rights and can Health Care. Fogarty International Center Series on

have recourse to a procedure for assuring these Preventive Medicine, Vol. 6. Washington, D.C., US Gov- rights. ernment Printing Office. —a —

Comprehensive and stable financing.

Obviously, the planning and capacity of it all becomes critical. INVITED DISCUSSION The issue of management rises to the fore. Ad- ministrators of the future require

1. Knowledge of the community and its culture, 2. Appreciation of a community board, William Kissick 3. Freedom to circulate, 4. Sensitivity to staff under stress, 5. Knowledge of labor relations, Summary Review 6. Appreciation of data processing, 7. Facility in formulation of objectives and Primary Health Care is defined as “an organized evaluation, for delivery system that accepts responsibility to care 8. Knowledge of quality of care, all residents of a defined community who wish to use 9. Appreciation of patient advocacy. of its services.” The physician is but one of a host With this portfolio, who would doubt that the ad- this responsi- health professionals who share ministrator of the future is the “linchpin” of the new bility. Primary care is but recently a focus of medi- primary care system. cal education. When one recognizes that primary care is delivered by private practitioners (78 per- Comment cent), OPD’s (Outpatient departments) and ER’s

(Emergency rooms) ( 18 percent), and Health Main- Although broad in scope. Dr. Gibson’s analysis of tenance Organizations (HMO's) and Neighborhood this most critical area is superficial. For this we must

Health Centers (4 percent), it is hardly surprising thank him. To have provided both breadth and that the family practice (primary care) movement depth would have required a tone which we could is not a creature of the medical schools and teaching not have skimmed let alone assimilated. hospitals. I agree with most of the presentation—as far as

The responses of academic medicine have been it goes. This well may be far enough, given the very three-fold: limited state of the art that surrounds our common

1. Family Practice—a passive acceptance of an endeavors—be we in Preventive Medicine, Pri- outside initiative. mary Care, Community Medicine, or Family Medi- 2. Community Medicine—a synthesis of preven- cine. tive medicine and clinical medicine, in search A few comments, if you will, by way of emphasis, of the community. as much as criticism.

3. Health Maintenance Organization (HMO) — ( The data presented on 567 million patient 1 ) delivery and financing system that appeals to visits for primary care in 1969 bear reflection. Family Medicine and Community Medicine While 4 of 5 patients consulted private physicians, for different but compatible reasons. A tenta- only 18 percent visited OPD's or ER’s and less than

tive concept at best, Kaiser notwithstanding. 1 in 20 utilized Neighborhood Health Centers or If these are indeed the current themes, what of the HMO’s. How could we investigate, educate and re- future? form the present in terms of opportunities for The author conceptualizes a 25-year forecast change, while writing the scenarios of the 1990’s?

1. Corporate primary care, A numerical assessment is but a beginning. What,

2. Focused on and based in the community, if anything, does an OPD or ER really have in com- 3. Populations of 3,000 to 50,000, mon with the primary care conceptualized by Dr. 4. Effective patterns of inpatient and specialty Gibson? care, (2) Family Practice needs a definition beyond 5. Health care teams, “that which a family physician does.” Likewise, the

6. Community center care, concept of primary care cannot long survive as the 7. Consumer policy input, output of two or more health professionals gathered

107 )

108 /Prevention in Primary Care together in the best interests of a patient, preferably is neither ‘state medicine,’ nor ‘socialized medicine,’ nor called a consumer or client. Admittedly, we have ‘private medicine,’ but a combined public and private time, for we have yet to challenge seriously someone effort for comprehensive health care in every American

community. ( Stewart 1963 else’s turf. But breathing room is not eternity. ,

Gertrude Stein notwithstanding, a family physician, For me, Community Medicine can be perceived func- is not a general practitioner, is not a primary care tionally, as an effort to merge medical practice with physician. public health (use preventive medicine if you will), (3) Count’s concluding description of the pri- followed by a synthesis of this whole with the social, care system’s administration of the future trig- mary behavioral, and systems sciences. This is what we gered recall of a pet theory. The changes within the are attempting at the University of Pennsylvania. organization and delivery of health services are going We are making more progress with the merger to be shaped more by the societal focuses outside (with public health) than with the synthesis. A medicine per se than by the developments and in- collaboration between the Department of Com- novations within biomedical science and academic munity Medicine and the Leonard Davis Institute medicine. The Flexner Report was a cultural phe- of Health Economics of the Wharton School has re- nomenon; admittedly with the help of organized sulted in a Graduate Program in Health Care Ad- medicine, but a societal achievement nonetheless. ministration, an interdisciplinary Research and The actual reform began in 1848 with the founding Development Unit, and an Advanced Management of the AMA and was concluded by NIH circa Program. An undergraduate major in Health Sys-

1950’s. When one recognizes that the Flexner Re- tems is in the planning phase. port was covered on the front page of the New York The Clinical Scholars Program commenced July Times, societal readiness is obvious. The lesson for 1974, and will focus on providing systems sciences us is that if we look about, we may find more allies skills to physicians who hopefully may become the in other social systems than we will among our col- Community Medicine specialists of the future. If leagues in academic medicine. If you suspect, as I Count's primary care administrators become the do, that he who pays the piper, calls the tune, we linchpins of the new system, these men and women might give equal time to Aetna, Connecticut Gen- will hopefully become the strategists and architects. eral, Metropolitan, and Blue Cross as well as It could be quite a combination. ATPM, AAMC, APHA, and AMA. We in health are in a political process, i.e., of, by and for the PEOPLE. (4) Finally, a plug for Community Medicine. I REFERENCES prefer the definition penned by William H. Stewart, M.D., (1963) who will probably be remembered as the last established Surgeon General of the

United States: Stewart, WH 1963. Community Medicine: An American

the specialized knowledge and skills required in our Concept of Comprehensive Care. Publ Hlth Reports 78:

emerging system of medical services, a system which 93-100. —

while trying to figure out the future. The University of Washington may have reshaped that monolithic structure. The secret of the Flexner report was the DISCUSSION existence of Johns Hopkins. Flexner, after criticiz- ing everything, stated what should be done, and said

one group was doing it the right way. The Univer-

sity of Washington’s strength in family medicine is

incredible. It is a young school, it is an exciting BUYSE: Let us now discuss the future role that school, and its biomedical research faculty can stack primary practitioners and teachers can play in bring- up against any medical school in the country. Is ing about change. Primary care people can be a anybody writing up the story, the case history of very powerful lobby because of their unique posi- what it is? How it is happening? We really learn tion in the community—the esteem, the prestige they from such a prototype. are almost automatically awarded. BAKER: They are writing bits and pieces about

FARLEY: The medical education system plays it, the initial go with the track system, which is the a fantastically important role in determining the cornerstone. The school decided to have a track medical care system. Much of the present inade- system with family physicians as one of the two quacy and inappropriateness of our medical care clinical tracks. The director implemented these de- system might have been avoided had medical edu- cisions, and the school has been built in that kind of cation concerned itself in the past with primary care atmosphere. issues. STOKES: To affect social changes two things are

In a sense, that is why I left a primary care prac- necessary, and the Flexner report gives an example. tice. After seven years of trying to find somebody First, you need a working model, and secondly, you who wanted to join an exciting practice in a nice need a salesman. Ralph Nader is an example of area and really develop something, I realized the both. He gets hold of good mousetraps, and then he medical education system said, “No, that’s nonsense, sells them. Now, you know, the University of Wash- be a cardiologist, be a psychiatrist, be anything but ington isn’t going to have an impact on American what you’re doing, because that absolutely can’t be academia unless it is sold. Just the fact that it is there good medicine.” Traditionally, we have been train- is not enough. ing doctors in sophisticated hospitals hoping that WALKER: The issue is: How do we bring about both the community’s and the doctors’ needs can be change? The mammoth amount of brain power avail- forced to meet. What we should be saying is, “Train able in academia and in medical schools is some- doctors who can meet the needs of the community thing to be tapped. And yet, it is pointed out that which includes specialists and subspecialists—but in by their nature most medical schools are poorly rational proportions and at a logical level of care suited to serve as change agents—the deans have rather than dominating care.” relatively little power, the departments wherein the Despite successes with our family medicine resi- power rests see their turf threatened by each new dency program and in spite of this workshop, I get idea. extremely pessimistic about the ability of the medical The effect that a regional health authority such education system to change. It is a monolithic or- as that proposed in the Rogers-Roy-Hastings bill ganization committed to massive departments that might have in changing the direction of medical edu- have minimal visions of what society needs. For that cation should be considered. Presumably this would matter, primary care could be as myopic as the rest derive from a mix of consumer and provider input if, for instance, it were to insist upon the solo gen- in deciding the needs of a particular area. eral practitioner as the exclusive primary care GIBSON: Several brief responses to these com- model. ments and questions. Firstly, I fully agree with Dr. KISSICK: We have one possible exception to Kissick’s earlier point, that the pressures for change this pessimistic outlook. I have a question for Dick in the medical curriculum are going to come from

Baker, provoked by my constantly looking in two outside the medical profession and its institutions. directions, trying to find historical precedence, The family practice movement is here because of

109 1 10/Prevention in Primary Care

Congress and State legislatures, no thanks really to ing hospitals, to transfer acutely ill patients to the the AMA or the AAMC. public hospital. My questions are, “Why can’t you Secondly, regionalization, where the medical treat the patient there? Why run the risk of the pa- school will play a key part in a larger system, em- tient dying in the ambulance coming to D.C. Gen- phasizing the importance of producing physicians to eral?” The response is usually, “Well, the patient meet the region’s needs. While not explicitly stated doesn’t have any insurance,” or “We just don’t have in the regional health authority bills currently being any facilities to take care of patients like this.” Two considered in Congress, it is nonetheless implicit in recent cases—a woman with an incomplete abortion these bills. and hematocrit, 19 years old, another suffering from Finally, while there is currently much emphasis acute appendicitis with unstable vital signs—are a on consumer inputs to health planning, the potential good illustration of what I mentioned previously. primary physician’s role in the current and future Finally, I would mention the lack of physicians cadre of change agents is an important one. This willing to practice within indigent communities, physician role will, however, be different from the both rural and urban. The popular notion of filling traditional one. Hopefully, consumers will not auto- such gaps with physician assistants is naive. In areas matically accept physicians’ judgments simply be- where medical problems tend to be most severe, it cause they are grateful for the physicians’ presence is hardly appropriate to look to paramedical per- in the community. sonnel to provide solutions. Again, the physician

SMITH: I commend Drs. Gibson and Kissick on assistant concept is one more suited to supplement their analysis of management and organization and the health maintenance type medical service needs the changing role of the private and public sector in of middle class communities. our health care systems—it looks very colorful. The In summary, these and other problems afflict the problem with this whole concept is in seeing where black community. We have to go back to the draw- the minority, or where specifically the black indigent ing boards and do more research on how to solve patient, fits into all of those changes. For instance, some of these problems. They are not the same

I can see some real problems with the HMO model. problems of middle America. If anything, they are

In fact, it has been said time and time again that more akin to health care problems of the indigent

HMO is not designed to support indigent patients. populations of developing countries. Only a middle class type clientele can understand GIBSON: Dr. Smith has raised some very crucial the model, can afford its services, and can partici- issues. pate in consumer boards, etc., if it is to work at all. The general reorganization of our society and

No system, the HMO or any others discussed here, liberation of the black community is critical and how has taken into account that in dealing with the in- this is going to be done is another long matter which digent minority, usually black population in this obviously we cannot begin to touch at this time. country, you are dealing with some real social evils But the whole economic basis and self-determination that do not exist in middle America. of the black community is what will ultimately be First, you don't have the consumer sophistication the crucial determinant, and not just a temporary that is assumed when you speak of a patient bill of solution. Until this happens, there are some things rights and of regional planning or community health that can and are being done to alleviate some of the center advisory boards. You have a few radical at- particular problems of minorities in dealing with tempts such as the Saluda group and the Black the medical care system. Panther group out in California, none of which ever Most important, each community can develop the really got a foothold on any type of system for de- sophistication to effectively participate in planning livering health care. for its medical services. There are many shrewd Secondly, there are the discriminatory practices in black consumers now as a result of some of the OEO providing medical services which are so familiar in neighborhood center .days. There are some very our society, particularly the cities. I illustrate this smart people now around Mound Bayou, Mississippi. by way of anecdote. I moonlight at D.C. General For example, the Farmers’ Coop has learned a lot Hospital as medical officer in charge during the about bureaucracy, as has Charles Evers, in Fay- midnight to 8:00 a.m. shift. Invariably, I receive ette, Mississippi. We will find that an increasing calls from other hospitals, usually university teach- number of black politicians and their staffs—the 1

Future Organization and Management/ 1 1

Black Caucus in Congress, for instance—have now can’t hire that way, but if hiring on a corporate acquired the power to begin developing some of basis, you can hire 300 nurses and spread them these things. across 350 situations. The corporate model approach

Further, a true national health insurance pro- is economically viable and it will be used in the gram should provide equivalent ability among all health area. parts of our society to purchase medical care. This Consumers will play an important role in Con- is crucial and it should do away with many of the gress decisions of legislation in the health area. The inequities, such as the one cited by Dr. Smith, Rogers-Roy-Hastings national health planning bill which result from our present system of financing proposes to create a council of health advisors out medical care. of the Council of Economic Advisors in the White SCUTCHFIELD: It takes money to change a House to determine priorities, allocation of re- system resulting from such inequities. Dr. Gibson’s sources, and other such matters. Priorities would be comment about a national health insurance which determined by a look at the whole problem, and would enable people to buy decent health care is regionalization would create health service areas, probably the only way it could be done. The same which would be viable and valid in time, but the is true of bringing about change in the medical edu- way it is presently structured, it would not work. cation system. Money will always talk. It will be the The decisionmaking powers would be potentially so only thing that talks. When there are funds avail- great and the pooling of funds so threatening to able for family medicine in the HEW budget, as many people in the health sector. The bill states proposed in the various health manpower bills in that if in a specified period of time the geographic Congress, then these departments will move. areas are not designated locally, the secretary shall

KISSICK: The issue is change, and the question designate them. It seems that the bill’s main pur- is leverage—where is it, what is it? My answer is pose will be a provocation of consideration, a de- economics. bate in dialogue.

Our percentage of Gross National Product ex- SMITH: I have a question for Dr. Gibson. When pended for health is now 7.7 percent. It is $94 bil- California implemented a program to control the lion (FY 1974), and projections for 1980 are in cost of MediCal, is it true that the cost for the State excess of $200 billion. This would be approximately did not change significantly because the money went 9.8 percent of the Gross National Product—one out into such areas as administration, third party con- of every $10 worth of goods and services produced! tracts, etc.?

This is the upper limit; we cannot cross it. Not be- GIBSON: When the MediCal reform was passed, cause of anything going on in the health industry, 40 additional clerks were hired to administer it. It but because the other sectors of society cannot toler- put a lid on the dollars going into the physicians’ housing, food, cloth- ate it. The portions needed for pockets and spent them elsewhere, with no real etc., to more ing, education, transportation, add up savings. than percent. The needs of society exceed GNP. 90 SMITH: Wouldn’t this be true with national ap- A study done a few years ago pointed out that by proach, alluded to by Dr. Kissick? Are we really 1980 according to current trends—we would need — going to stop the escalation of the cost of the product 25 percent in excess of GNP to meet our societal by changing it into the corporate stream? needs. Obviously, we are going to meet some; some KISSICK: A corporation does not necessarily we are not. Here we get into political decisionmak- have to be national; it can be local or regional. The ing, dealing with what Saward calls a “closed United States will not approximate the British Na- budget.” tional Health Services. It is one large V.A. Stop and In the midst of this we are going to find an in- think about it. It is not consistent with our ideology creasing presence of the corporate model. An HMO could be one corporate model; Harvard has one. and the way we do things; it wouldn't work if we tried. approach will be different. By corporate There is a proposal by Leonard Cronkite for a de- Our centralized franchised family physician with support I mean that there are other aspects to the delivery services in terms of information systems, billing, an- of medical care than those deemed important by cillary health manpower, etc. There are situations members of the medical profession, who do many when a doctor needs one and a half nurses. You thing inefficiently and ineffectively, often at exorbi- 112 /Prevention in Primary Care tant cost. Corporations take time and energy to effectiveness and professional satisfaction. This ferret out these things. The physician will not be should apply equally to the teachers, practitioners, subjugated by this. He can have an even greater and managers of the medical care of the future. SUPPLEMENTS

As an outgrowth of informal discussions among symposium participants, certain important points of view, which were not amply covered in the original deliberations, were identified and subsequently short papers on two of these issues were written and submitted to the editor. They are included as supplements to the symposium.

The first paper, by Drs. Payton and Smith, both family practice residents at the University of Rochester, provides a systematic and rea- soned analysis of those aspects of preventive and community medicine which they deem of particular importance to their primary care practice. They offer suggestions for integrating such teaching into the primary care training setting. The second supplement, by Dr. Falk, focuses upon some special problems of women and members of minority groups in entering the mainstream of the medical educational establishment in this country.

Attention is drawn to the experiences of Meharry Medical School in developing community medicine and primary care teaching resources. The paper includes a brief social history of some roles and concerns of public health: women, black, brown, and native American health workers in our society. It presents these questions as social policy issues, and therefore requiring legislative and administrative attention. I became during their nine or more years of higher

education, the more impossible it became for them to feel the experiences of their patients and neigh- PREVENTIVE / COMMUNITY bors. Maybe it would be better to call this “decul- MEDICINE ROLES IN PRIMARY THE FAMILY turation” from society’s point of view. The need for CARE EDUCATION— facilities and technology also took practitioners to RESIDENT’S PRACTICE PERSPECTIVE major population centers, making care unavailable to vast segments of our population. Second, students witnessed the abrogation of medicine’s responsibility to family and community. C. Payton and S. Smith It gradually became more difficult for families to

find a single locus of care for all of their members. Though rarely trained for the task, the vanishing BACKGROUND general practitioner, because of his relationship with most members of any family, was able to recog- The results of two decades of Federal subsidies in nize and respond to the problems that cause indi- medical education are well known. This country has vidual illnesses among relatives and within the experienced improvements in subspecialty care community. Because this physician in many cases previously unmatched. In the early 1960’s students served in various civic activities, he was able to for the first time either felt the lack of opportunity, either stimulate the development of public health or ventured the impudence to point out how iso- services or initiate and coordinate the provision of lated they were from basic societal needs in health. these services to his patients. The authors would

Because the movement initially dealt with social re- prefer to avoid the word “patient” because it is sponsibility in areas such as equal voting rights (the illness-oriented and carries the connotation of de- freedom rides of 1963), the movement became pendency. Since it is generally accepted, we will known as community health. Though Richard continue to use it, however, with the understanding

Weinerman, George Silver, and others had written that it describes the relationship between health pro- about socioeconomic concerns in health, it wasn’t fessionals and all of those clients or nonclients for until the sixties that health professionals generally whom they feel a stewardship responsibility as aptly accepted the causal relationship between national defined by John Millis (1966). politics and individual health and welfare. The ma- Third, it became quite obvious that the explosion jor stimulus did not come from our intellectuals in of health knowledge made it henceforth impossible the education establishment; it did not come from for comprehensive care to be delivered by a single practicing health professionals; it came from stu- practitioner. The consequence of this has been the dents! Since the mid-sixties, over five thousand reorganization of manpower into teams of personnel health science students have participated in projects dependent on sophisticated measurement tools for sponsored by SHO (The Student Health Organiza- determining health needs of individuals and of tion), SAMA (The Student American Medical population groups. They have demanded the use of Association), and numerous local collections of ag- constantly improving methods for patient informa- gressive, innovative students. tion storage and retrieval. Some of the lessons learned by these students are Lastly, this generation inherited the legacy of important in understanding the present thrust to- ever-increasing costs for the multitude of services ward primary care and why the disciplines of now available and an appropriate public concern

preventive and community health are integrally re- for the quality of care that is given. Because of these lated to primary care. pressures today’s physicians must be more aware of First, the trend toward subspecialization took new organizational concepts which will promote care-givers further and further away from their con- greater efficiency. Through such innovations as stituents. This was true at the interpersonal and POMR (Problem Oriented Medical Records), stu- geographic levels. The more acculturated physicians dents can engage in personal and peer review.

115 1 16/Prevention in Primary Care

CHARACTERISTICS OF PRIMARY CARE the authors feel should be part of primary care train- A discussion of the kind of preventive health pro- ing. Postgraduate experiences are not required. In grams fundamental to primary care training should fact, many could and should be part of the medical, be preceded by an analysis of primary care needs nursing, and other undergraduate’s primary care and practices. The parameters we will use are not oriented education. new, but their restatement is essential. Problem Identification Quality of care is an overriding concern which recipients can assess for appropriateness and ac- —Work with consumer boards ceptability, and which practitioners can assess for —Survey and sampling techniques scientific competence. From the consumer’s stand- —Use of medical records to indicate existing point, the application of limited health resources major problems must respond to priority needs. A means for estab- Preventive Care Design lishing priority must be available to those planning health services within a community. —Assist in creating health maintenance program

Comprehensive care is an issue within the primary 1. Cost effectiveness care level as well as between primary, secondary, 2. Patient monitoring system tertiary levels of care. Practitioners need a broader 3. Internal research protocol view of health than the classical “medical model” Quality Care which typically relies on an organic failure to justify therapeutic intervention. There are two concepts that —Peer review mechanisms need modification. First, that causal factors must be —Record system for ease of assessment (software) organic. More attention should be given to environ- —Use of flow charts mental factors, such as industrial hazards which Continuity and Comprehensiveness predispose to physical injury and illness, and to socioeconomic conditions, which influence emotional well- —System-patient interfaces (where, when) being. Secondly, that practitioner involvement need —Medical records to aid each practitioner only be directed at negative deviations from normal —Style of team practice health indicators. Antismoking and pollution cam- Community Elements paigns are examples of our limited efforts to actually elevate our normal health standards. —Environmental health Continuity of care is a concept often attached to —Industrial health the intensity and longevity of patient-provider rela- —School health tionship. Indeed, for some populations, an ongoing —Public health education relationship with a limited number of providers is —Social services an element of acceptable care. Intuitively, it also Organizational seems reasonable that this is a more rewarding experience for many practitioners. These are subjec- —Regionalization tive considerations which must not be disregarded, —Financing mechanisms but more critical to the theme of this paper is the more objective correlation between continuity and INSTRUCTIONAL METHODOLOGY quality care. In this area, continuity can be estab- Problem identification is a fundamental skill that lished between a health system and the individual all health workers develop to a greater or lesser de- client or community. To accomplish this, the memory function must become more mechanical. The medi- gree. For most, it is limited to clinical disease orientation. The teaching model in primary care should cal record is the heart of the health system’s opera- give a more catholic view, stimulating practitioners tions. Records must be complete, easily interpreted, to probe for environmental and social causes of and readily available to all the providers within the determinants of care within this system. disease and community. CURRICULAR OUTLINE The introductory statistics courses in medical

Below is an outline of the nonclinical elements school usually lack relevance for students, and prac- Resident’s Perspective/\ 17 tical tools are usually forgotten by the time one ap- careful studies on the variety of organizational sys- proaches active practice. Working with consumer tems now in experimental phase should be made. boards not only provides input on problem priorities Preventive medicine faculty, besides designing and but represents a significant first step at health edu- conducting these studies, should give new practi- cation. Both these areas are potential for direct in- tioners information that will help them change to the volvement of preventive medicine faculties. Primary style of practice that best allows them to meet a care trainees would learn by participation and di- combination of professional and public needs. rect observation. In this and other contexts, trainees Surprisingly, community health at the under- would work under the direction of preventive medi- graduate level is often taught by departments other cine, constructing and carrying out survey and than Preventive Medicine. Students are introduced sampling procedures that have direct pertinence to to various health care settings without knowing how the service institution in which they work. Preven- to interpret their observations and how to assimilate tive medicine can also work with trainees in the de- the experience in a meaningful way. The issues that sign of record systems that, not only aid in the need to be raised with students include superficial clinical practice, but are useful for identifying prob- descriptions and evaluations of the population re- lems of populations. Our bias is that Problem Ori- ceiving care, resources available, either publicly or ented Medical Record (POMR) is the heart of the privately, and the organization of resources as it in- system. Methods must be developed for abstracting fluences the pattern of care. Because community and storing this data for the individual persons and health implies concern for problems of population practices. Faculties must be familiar with various rather than individuals, the bulk of services in this approaches, such as “E” books (Eimerl, 1969) for area have been generated by preventive medicine coding diagnoses. This will enable them to give and public health types. The specific services that primary care providers an understanding of their will continue to fall in their purview include environ- usefulness. mental and industrial health. Primary care provides Preventive medicine should also have a critical an excellent opportunity for practitioners to work as role in the move toward an effective health mainte- team members with public health and social service nance program. Epidemiologists and statisticians officials. By learning to communicate at this level, it should collaborate in providing us with the morbid- is possible to most effectively approach those health ity information about various modes of intervention. needs of individuals which require intervention in For key illnesses we must know whether to rely on socioeconomic systems/institutions. Though pri- risk factor information to provide pre-illness serv- mary practitioners will probably not intervene in en- ices, make intense efforts at early acute diagnosis vironmental and industrial health, they will share the and treatment, or postdisease rehabilitation. In- responsibility for identifying and reporting health structors of primary care trainees can help interpret problems in these areas. Meeting the need for pub- the available literature on morbidity and mortality, lic awareness and competence in self-care and early cost effectiveness, and systems design for patient disease detection will require combined efforts by monitoring. These tasks can be accomplished by as- primary practitioners and their community health sisting in the design of such activities for the model colleagues. Some of the content and methods of de- practice units in which trainees work, providing livery could reasonably be taught by public health syllabuses with appropriate literature, and conduct- educators. ing seminars for trainees. Another area in which the measurement and de- Quality review may not be a subject to which sign tools used in preventive and community health preventive medicine addresses itself directly. Its are of value is in developing continuity at the contribution to better record systems and monitoring patient-provider interface. programs can significantly improve the effectiveness, The evolution of practice over the last decade however, with which PSRO’s and other such agencies has diminished the continuity that is available can operate. through personal interaction between the patient The authors see comprehensive care as an issue and an individual practitioner. As physician part- mainly of the organization of services. Since medi- nerships increase, the role of the medical record and cine has passed the landmark when it can meet the team communications becomes more crucial. These full breadth of health needs as a cottage industry. are purported to allow continuity to exist between 1 18 / Prevention in Primary Care a patient and an institution. However, little informa- In summary, the authors’ expectations of teachers tion exists about the adequacy of these substitutes of preventive and community health are extensive. and how their value is optimized for the institutions They are no more unreasonable, however, than the that choose to go this route. Such evaluations demands made of other disciplines to move from should be an ongoing activity of model practice the “pure” to “applied” sciences in providing pri- units in which primary practitioners train. Once mary care. We invite them to join the coming again, the role of preventive and community health revolution in medicine. is working side by side with trainees in accomplishing this goal. The remaining curricular goals deal with macro- systems and the determinants that will shape the overall structure of health care in the future. The REFERENCES major emphasis of recent legislation has dealt with the regional organization of services and the restructuring of health financing. Community health Eimerl, 1969. Handbook of Research in General faculties are usually the most informed members of T A Practice, The Royal College of General Practitioners. the academic community. They can serve as the England, E and S Livingston, Ltd. nucleus for periodic seminars that give trainees an overview of such issues as comprehensive health Millis, JS 1966. Report of the Citizens Commission on planning, regional medical programs, National Graduate Medical Education. The Graduate Education of Health insurance, and prepayment systems. Physicians. Chicago, American Medical Association. nantly black school, seven years ago (1967) with a recent background focused on health administration, MEDICAL EDUCATION health care delivery, occupational medicine, health planning and the financing of health services. I got FROM THE PERSPECTIVE to these from antibiotics research and nutrition OF MINORITY GROUPS— interests (which led me into the preventive medicine- A SOCIAL POLICY ISSUE public health world). I then added medical sociology and medical history as concentrations in the basic disciplines. Meharry Medical School had a marginal image in Leslie Falk October 1967. The big question was whether it

should survive, or whether it should “go out of business.” These years at Meharry have demonstrated to BACKGROUND me the importance of the black-led institution. Me- harry’s keen ear for the community minority and in discussion of Dr. Robert Berg urged us our poor population’s needs, its efforts to work with the

social policy issues to bring up some “here and now” consumer, and above all its faith and demonstration examples, as well as some long term ones. This that the black man or woman can become a good will include that effort. discussion doctor, are precious attributes. Fortunately, it is be- We have established by now that primary care and yond the bootstrap-raising level now and becoming community medicine are “in it together,” even a first-rate institution. though they are separate disciplines. But what is the An Office of Equal Opportunity-financed Neigh- “it”? Do we define “it” the same way? The specific borhood Health Center, now called the Matthew policy level has social meaning of things at the social Walker Health Center, was built in 1969, the first examples. Both to be described at this point by some major construction at Meharry since 1931. This is an the family practice and the preventive medicine important fact for some of those who may have for- movements have had great difficulty identifying with gotten the key role which the “poverty program” black, brown and red people, women and poor white played in that period. “Consumer participation,” populations, at least from the viewpoints, beliefs and consumer involvement and identification, meant to to under- cultures of those “minorities.” We need it, and to other medical schools, a fresh breeze stand this historically. We have to deal with the role through sutffy corridors. of women as healers, and the nature of the healer in We set up four family health teams, with our minority cultures. What has it meant to get an primary care as the center of the model. These teams education in a white, male-dominated medical school serve an inner-city population of some 40,000 peo- system in the United States? What were the problems ple, predominantly black, with some 12 percent low- of the two black segregated schools—Howard and income white, mostly very young and very old. The of minority Meharry? What about the small group term, “family health team” meant, at first, a mix of practitioners who did develop? Are there great re- physicians, nurses and health workers working in sources of talent in the minorities which can be ten-room suites. Primary care physician meant either tapped much more than they have been in the past? an internist or a pediatrician; family medicine physi- If so, can they get past the defeating behavior of cians had not appeared on our scene. In other words, some medical school faculty members? In short, how Meharry had not yet gone the route of identifying can we of the white-dominant group “turn our hear- with the family practice education movement. The ing aids” on better to minorities and women, and initial expectation that some older general practi- listen to their vocabularies, their ways of thinking tioners might want to return did not occur. This

and acting? seemed to be primarily an economic fact, i.e., the Let me speak personally now for a while. income which one accumulated was not competitive. However, we promptly introduced the expanded Meharry Medical College nurse role. The public health nurse who had visited

I came to Meharry Medical College, a predomi- the ill in their homes, logically merged into the nurse

119 .

120/Prevention in Primary Care practitioner. In this primary care teaching role, the ings and new models including a private practice nurse practitioner does not practice independently group. unless the family health team is without a doctor. She About half of the students now have their precep- is given more responsibility if there is no doctor, but tor placement in off-campus arrangements. One is she is still supervised on the premises. an epidemiological placement with the Tennessee In this setting, our clinical year medical students State Health Department located in Nashville; an- negotiated with the health center’s Consumer Health other is tuberculosis control. Organized health care Council to participate in the patient care activities. delivery systems are used in areas such as Jackson, Students could not be introduced into the center im- Miss., Chattanooga, Chicago, New York City, and mediately because the community did not trust them. areas such as the Lee County Cooperative Clinic, Health center professionals and the faculty were Marianna, Arkansas, and the Mound Bayou, Missis- smart enough not to push the issue. The students and sippi Delta Health Center where we have attempted the consumers themselves worked out a successful to build on what they and Tufts accomplished. Spe- agreement, which has worked beautifully now for cifically, we are developing a broad educational five years. Since 1969 the Department of Family and program as part of an area health program centered Community Health has had a core rotation of six at the community hospital. weeks, with a controlled number of clinical year stu- Tuskegee is another example of Meharry area dents. (We also have a good deal of earlier core health education relationships. It has emerged from time, 36 hours in the first year, and 72 hours in the the days of segregated education when it was neces- second year. So we are in a fortunate access situation sary that black residents go to places like Tuskegee. with all the medical students.) At first, eight students It left behind dozens of capable physicians who were were assigned as clinical clerks to the Matthew willing to teach. The Tuskegee Area Health Educa- Walker Health Center, combining in one six-week tion Center represents another easy planning entity clinical rotation the two fields of community medi- in which to work. cine and primary medical care, attempting their uni- The rural and the inner city shortages are a reality fication. The educational goals are: patient care which we experience clearly. Some of our education competence; understanding the primary health team involves the student and the resident in a listening- and primary care provision; basic preventive to-the-consumer session. A delegation is likely to medicine-public health competence; community di- come in saying “Can you find us a doctor?” How agnosis and community “prescription” (health plan- you work with this community, expressing what it ning or social action) thinks its needs are, is basic. We attempt to make a We are working towards the “same-time-same community diagnosis and prescription, to build more place” kind of educational goal for the student closely what’s feasible, and give some professional health team. This is terribly difficult as anybody who interchange on what the model should be, rather has tried it knows. A wonderful opportunity devel- than the fruitless “knocking ourselves out” task of oped from the beginning—a weekly family health trying to recruit a solo practice doctor for a rural team conference, including all the health workers of community. The extent to which the academic unit of a family team and any students working in that team. students, residents and faculty can set up models

At this conference someone gives an on-the-spot, which will influence students is an important high real-life case, or a report on a patient-case or an priority effort in our educational program. epidemiological, health care organization, health and A western Tennessee project in Fayette and Hay- human values, or biomedical ethics case. wood Counties, two of the poorest counties in the In 1972, an on-campus health care delivery country, provides “Health Fairs” with multiphasic model, the “314-E” Comprehensive Health Center, screening and followup of positive findings. We was developed. It serves a second defined population, identified the health problems, health rights, and and includes patients from the rest of the predomi- health services needs, and the result is a community nantly black neighborhoods of Nashville. A Children center with one doctor, one nurse practitioner and and Youth program and a Community Mental Health health workers.

Center, which are part of the organized ambulatory An example is necessary to indicate how we team model are also on campus. All ambulatory combine and identify health and health services services have been transferred to these new build- needs. We discuss the difference in the inner city Perspective of Minority Groups/] 21 between identifying pulmonary disease and its re- Social History lationship to air pollution, to person self-pollution In relating the historical development of commu- through the cigarette, and pollution relation to oc- nity and primary medicine. I will expand a bit beyond cupation. These are all different levels which we try this paper. Both fields have a historical advantage to relate to primary care. For example, asbestos is in that neither has developed from the “gentleman practically ubiquitous around us all, both in en- physician” (nonmanual labor type). In the 19th vironmental air and in occupations, like heating and century the general practitioner came from the lower ventilating. But is asbestosis, as a disease? It is a or middle class; perhaps he was an apothecary, cer- little more difficult to get people excited about smog tainly not a learned “gentleman.” Public health, the control in the inner city, particularly in a black com- precursor to community medicine, was part of the munity where rats run across the street, and students “reform movement.” It was involved in problems of easily say, “Man, you’re trying to put us off with this contaminated drinking water and other such hazards. kind of indirect political stuff. Where can we get on Both community medicine and primary medicine had smog? You got to change the system. Let’s clean up to face the pressing problems of daily life, with little the rats; we hate them.” So we say, fine, let’s give time to keep up with new research, and thus did not attention to rat control. What does that mean in always provide the best and latest services. social policy. Ultimately, the “power structure” Women: Woman’s role as midwife progressively (slum-lord influence and political process) surface. began to lose its legitimacy, particularly in the United In this instance, what is the consumer’s role, includ- States. Medicine has been male-dominated in the ing the citizens’ health council, if any? After it is United States historically and this should be under- demonstrated a couple of times that a medical stu- stood, recognized and consciously corrected. dent delegation “didn’t get anywhere,” we settle Black Doctors: The black doctor also has been down with the values and efforts by which they live discriminated against in the United States. By main- their lives. taining independence and loyalty to the black I hope I have given a bit of flavor to the attempts race, African culture was a threat and had to be de- of family practice and community health, despite stroyed. Slaves could not legally become doctors be- their differences, to feel comfortably at home to- cause it gave them the freedom which could be used gether. It is easy to shove Preventive Medicine- against their masters, and also it was dangerous for Public Health Part II National Boards under the a slave to move around. Tennessee is an example of noses of clinical students, as a necessary learning that which occurred in all the slave-owning States. objective to be able to practice. In family practice, Laws were enacted forbidding slaves to become doc- patient care competencies and family knowledge and tors. Life was vicarious and full of prejudice against skills are the necessary objectives. We will gladly blacks—free or slave. New York abolished slavery supply a detailed list of educational objectives to as late as 1835. The Civil War and Emancipation those interested. Proclamation came only 30 years later, both pre- We are biased toward the organized practice ceded and succeeded by segregation, discrimination, teaching model rather than toward the solo practi- race riots, and exclusion of blacks from the best edu- tioner model. We have sought out the organized cational opportunities. health team delivery system, and have a series of Brown Healers and Native Americans: Another such arrangements—rural and urban. One is an all- example of discrimination exists toward the brown white, four doctor (two males and two females) race—the Chicano—and the American Indian. The family practice group in a rural county seat an hour’s Chicano had the unavoidable migrant health prob- drive south of Nashville, in Shelbyville, Tennessee. lems, the language barrier, and their superstitious be- The county hospital is across the road. We have liefs about illnesses. The American Indian also had given this model a high priority. In this case, the cur- his rent president of the Tennessee Academy of Family own beliefs about illness and well-being. The medicine man’s role Practice is a member. The practitioners on this team as healer is an aspect of the are “eager-beaver teachers,” and are rated highly culture of the Indian that should have been under- among field faculty preceptors in effectiveness. We stood in its context. It is clear, of course, that the have a guide containing our educational objectives to relationship of poverty and dependency is crucial help our field faculty in evaluating students. among these minorities. 122 / Prevention in Primary Care

Other Health Workers: In addition to the physi- Our research in health services can help clarify cian—in prevention or in primary care—there is the the effectiveness and improvement of these models family health team. Almost automatically, in talking for health service delivery. For example, can we con- of the family health team, the primary health team, firm that the patient counseling and education role the preventive health team, one visualizes the nurse is more successfully done by nurses than by physi- and other health workers. We must incorporate into cians? There are some leads in the health services our education actual health team models. Role re- research literature that this is a fact. For example, lationships are crucial. We must give students op- diabetics understood and remained on nurse- portunities to learn the right models, as well as the explained diets better than on M.D. -explained diets. “wrong” model of the declining, isolated practitioner. Thus, we must evaluate both models and contents, If we present only one model we can slow the future considering patient satisfaction and health mainte- in favor of the status quo. nance, as well as disease and treatment specifics. 1 1 1 1

Contract, physician’s, 16 Core competencies, 23

Corporate model, 1 1 INDEX Cost effectiveness, family medicine, 85

Council of Economic Advisers, 1 1 Crombie, D. L., 80

Cronkite, Leonard, 1 1 Cross, H. D., 66 American Academy of Family Physicians, 6 Cultural differences, 91 American Academy of General (Family) Practice, Data keeping, 51, 63, 79f, 85, 90 43, 87 Defects, prevention of, 75 American Board of Family Practice, 6 Diagnostic and preventive procedures, 25 American Cancer Society, 29 Diagnostic index, 50 American Public Health Association, 39 Disease, 24 American Red Cross, 29 early detection of, 45 Arizona, University of, 99 Doll, R., 38 Association of Teachers of Preventive Medicine, 7 “E” Books, 117

Attitudes, 37f, 41 f Economic Opportunity Act, 89

Behavioral science, 4, 73, 9 1 f Educational resources, 54 Bennis, Warren, 18 Eimerl, T., 50

Bentsen, B. G., 80 Elstein, A. S., 76 Biostatistics, 89, 96 Environment Bjorn, J. C., 66 in medical education, 46

Bush, J. W„ 73, 77 in preventing illness, 74, 79 California, University of modification of, 74 at San Diego, 74f Environmental and occupational health, 92ff, 116

Cassel, J., 74 Epidemiology, 4, 13, 41, 45, 50, 79, 89ff, 96, 117 Charney, Evan, 85 Evaluation, in primary care, 76 Clinical preventive medicine, 10 Evans, Robert, 66

Clinical trials, 76 Faculty, requirements for, 52 Clinician, 16 Family, as institution, 18 Community diagnosis, 97, 100 Family Counseling Service, 29 Community health, 4 Family medicine, 5ff, 18, 43, 87 resources, 28f, 46, 90 defined, 10 Community medicine, 4f, 9f, 13, 27f, 45f, 104, 107, difference from community medicine, 14, 96

117 educational advantages, 1 and preventive medicine, 13f educational objectives, 90

definition, 10, 27f, 108 educational problems, 6, 9 difference from family medicine, 14, 96 legal aspects, 26 educational objectives, 5 research, 76 educational problems, 9 resident movement, 104 evaluation of performance, 3 If role of, 17 evaluation of training, 41 Community mental health center, 28 structure, 51 Competency, 23, 45, 61 Family Medicine House Officers Manual, 53 Competency-based objectives for family physicians, Family Medicine Program, 23, 37f Rochester, 44, 46

Comprehensive care, 87 Family physician, 6, 12, 14, 17f, 23f, 43 Consumer advisory groups, 4 If, 5 If, 64, 105 Family physician pathway, 23, 42

123 1 1 1

124 /Prevention in Primary Care

Family practice, 10, 18, 107 Kaplan, N. M., 9 legal aspects, 26f Kentucky, University of, 97 movement, 103f Kern, F., Jr., 42

training programs, 11 Kinlen, L. J., 38 Farquar, John, 73 Lancaster General Hospital, 63

Flexner Report, 1 08f Library, medical, 54 Flow chart, 51, 63 Magerian behavioral objectives, 41

Froom, Jack, 50, 85 Matthew Walker Health Center, 1 19f

GNP, percent spent for health, 1 1 McGavran, E. G., 97 Geiger, Jack, 17 McGaw, David, 66

General practitioner, 5, 115 McWhinney, I. R., 76 Geographic record filing, 50 MEDEX, 15, 62, 64

Graduate medical education, role of, 3 MediCal, 1 1 Group Health Coop of Puget Sound, 104 Medical education, responsibilities, 3 Guidelines for Family Practice Residencies, 47 Medical social worker, 14 Gynecologist, 15 Meharry Medical College, 11911

Hall, J. H., 10 Metcalfe, D. H. H., 50

Hamilton Health Center, 62 Millis, John, 5, 43, 52, 1 15 Hammond, K. R., 47 Minority students, 3

Harvard University, 1 1 Mississippi Delta area, 17, 110, 120 Health care Model Family Practice Unit, 87 deficiencies in delivery, 43 Model practice unit financing, 93 Hershey, 62ff

Health care team, 3, 25, 62, 88 Rochester, 47ff administrator, 17 Model system for primary care (future), 104ff Health educator, 45, 75 Montefiore Hospital, 18

Health fair, 120 Morris, J. N., 90 Health information systems, 76 Moser, Kenneth, 75 Health maintenance, 25, 92 Multiphasic screening, 38f, 42 forms, 25, 33ff Multiple Risk Factor Intervention Trials, 76 grid, 51 National Commission on Community Health Ser-

organizations 6, 68, 104, 107, 11 Of vices, 43 Health science centers, responsibilities of, 9 National health insurance program, 111 Health screening, 45, 75 National Health Service (British), 79, 85, 111 Hershey Program, 6 Iff National Heart and Lung Institute, 76 Hilleboe, H. E„ 38 Neighborhood health centers, 55, 96, 99, 100, 107 Horowitz, Sue, 15 Nurse, 28, 49, 88

Hospital organization, 30 Nurse practitioner, 14, 48, 88, 105, 1 1 9f Host, protection of, 74, 79 Obstetrician, 43

Howard University, 119 Occupational health, 7, 92 Immunization, 44, 61, 75 Occupational history, 42, 92 grid, Outcomes of health care 5 1 , 63 systems, 42 Indigent populations, problems of, 74, 91, 11 Of, Outpatient services, 6 120f PSRO, 93 Industrial medicine, 18 Patient education, 45 International health programs, 42 Patients Bill of Rights, 106 Internists, 5f, 12, 15, 43 Pediatrician, 5f, 15, 43 Jason, Hilliard, 52 Pediatrics, 87 Johns Hopkins University, 109 Peer review, 51, 90, 115 Joint multiple appointment system, 52 Pennsylvania, University of, 108 Kaiser Health Plan, 104, 107 Pennsylvania State University, 61 Index/ 125

Periodic health examinations, 45 Rockford program for primary care training, 66f Physician’s assistants, 5 Rogers-Roy-Hastings bill, 109, 111 Preventive medicine Royal College of General Practitioners, 49, 54, 65f competencies, 44 SAMA, 115 definition, 10 SHO, 115

educational objectives, 4, 7, 13, 23ff Sackett, David, 37, 39 educational roles, 10 Salvation Army welfare services, 29 elements of, 44 Schneiderman, L., 74

problems in, 4, 9, 13, 73 Secondary prevention, 45, 61 Preventive methods used by primary physician, 79 Shimkin, Michael, 37 Preventive strategies, 74 Silberman, C., 11, 79 Primary care Silver, George, 18, 115 administrators, 14, 105f, 108 Smith, D. H., 76 and periodic health examinations, 7 Social disorganization in disease, 91 characteristics, 116 Social services, 28 combined with preventive medicine, 7f, 13 Society of Teachers of Family Medicine, 87 cost-effective training, 11 Stanford University, 18 definition, 10, 15f, 103, 107 Statistical principles, 51 disciplines, 87 Strategic method of disease prevention, 75 educational objectives, 5ff Student-faculty ratio, 52f model system, 104f Subspecialization, 115 physician, 17, 89 Surgeon, 5 team, 88 Systemic sclerosis, 74 Primary prevention, 44, 61 Tactical method of disease prevention, 79 Problem-oriented medical record, 50f, 63, 115, 117 Teaching resources, structure of, 46 Project Health, 69 Team approach to patient care, 62 Prophylaxis, 75 Thompson problem solving matrix, 38 Protection of host, 74f Topler, Alvin, 18 Public health department, contrasted with medical Treatment procedures, 25 school, 9 Trusteeship, 16f Public health schools, isolation from medical schools, Tufts-Delta Health Care Program, 74 9 Utah, University of, 12 Rau, Wolfgang, 74 Veterinary training, 17 Record system, 49, 116 Visiting Nurse Association, 28, 42 Red Cross, 29 WAMI program, 15 Regionalization, 110 WHO, 44 Registry, construction of Washington, University of, 23, 42, 97, 109 Hershey, 63 Weed’s Problem-Oriented Medical Record, 50f Rochester, 49 Weinerman, Richard, 115 Rehabilitation, 45, 53f Western Ontario, University of, 79ff Research, in primary care, 76 Westside Health Service, 55 Residents, selection and training, 23 Wharton School, 108 Hershey, 63f White, Kerr, 96 Rochester, 48, 53 Whitehead, 42 Robbins, L. C., 10 Willard Report, 43 Rochester, University of, 48f, 53, 85

*£? U.S. GOVERNMENT PRINTING OFFICE: 1976 O 202-506

1 DATE DUE

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